A Very Brief History of Psychotherapy

‘[B]y raising pity and fear, or terror, to purge the mind of those and such like passions, that is, to temper and reduce them to just measure with a kind of delight, stirred up by reading or seeing those passions well imitated.’ Milton, Samson Agonistes (1671)

Tragedy and Catharsis

The powers of tragedy and catharsis for the baroque poet John Milton were clear. Yet emotional and psychological responses to psychical crises can be traced far further back through the weave of history (and historiography). We may recall that in ancient Greece, as early as the sixth century BCE, calls for a rational explanation to account for the relationship between particular and general, private and public arose. Here the Sophists (e.g. Protagoras and Gorgias) were to be among the first to unveil what today is called the experience of human subjectivity. They did so by bringing to light a problem inherent in every human being as such from internal report. That is to say, a subject was situated as one who feels and desires, one who is capable of asking him or herself questions about themselves and about the world, a subject whose very existence conditions at the same time both the question and the answer.

The Sophists great antagonist, Socrates, was to provide moral significance for this interrogation of human by human. Socrates’ dialectical irony (Gr. maieutic) - inspired by the inscription on the Delphic Temple, ‘Know thyself’ (Gr. Gnothi Seauton) - brought to introspective analysis a method that lent itself easily to generalisation. This dialectic method laid the foundation for introspective psychology which was to undergo, in future centuries, countless variations, all of which inscribed on the royal road opened up by the Philosopher himself. The dramatic tragedy of crisis followed by purgation under Plato saw Socratic teaching blossom into a grandiose metaphysics, affirming the eternity of the soul (psyche) and the mundane destiny of the body (soma) (see PHILEBUS, PHAEDRUS, TIMAEUS, PARMENIDES, REPUBLIC) . Whilst in Aristotle there can be said to be a clear suggestion for the primary component in the earliest recognitions of the therapeutic value of containing, encouraging and consoling patients. In Aristotle one finds the earliest recorded evidence for a medical catharsis (?a?a??e??) found in the POLITICS, where the association is explicitly made between religious music and a medical catharsis. In this sense Aristotelian catharsis presupposes the Hippocratic notion of the same name. It was thus that the great physician Hippocrates, in the fifth century BCE, appeared to be the initiator of clinical observation (hypothetico-inductive inference). The philosopher Epicurus (b. 341 – d. 271BCE) and his close colleague Metrodorus (b. 331 – d. 278 BCE) quested for a narrative to describe inward tranquillity. Their concern with interactions between the body (soma) and the soul (psyche) are still found in modern psychotherapies. These interactions led Epicurus to think that the soul and the body were of the same nature (monism), that is, the soul was considered to be of the same material substance as the body, yet composed of more subtle fundamental elements (LETTER TO HERODOTUS, ON NATURE). Such a materialist solution was to reappear in the modern world through the school of thought known as Behaviourism. Nonetheless the Epicurean stance rests on a phenomenological principle concerning representation that all sensations are true.

The Age of Reason

The supervening cultural transformation known as the Age of Reason brought with it a paradoxical return to a trenchant belief in the transcendental as the primary source for mental illnesses. At this time the work of a mathematician and philosopher, René Descartes, came to prominence (MÉDITATIONS SUR LA PHILOSOPHIE PREMIÈRE, 1641). Descartes’ reductionism argued that the physical universe was composed across two extensions: matter and space. Convinced that the laws of nature are, in principle, reducible to those of motion, he treated biology as though it were a branch of physics. The functions of living bodies would thus result mechanically from the arrangement of the organs. The animal, to which Descartes refused to grant any consciousness, is for him nothing but a machine, an automation. Having discovered his first principles, Descartes’ scepticism led him toward the ‘Cogito ergo sum’ and the reality of thought; whose immateriality made it impossible for thought to be reduced to matter and space. Descartes attributed a unique absolute originality to the human soul. By thus affirming the coexistence of the two principle substances of Space (res extensa) and Thought (res cogitans), the Cartesian doctrine of substance dualism was also able to foster the revival of introspective psychology as well as mathematical physics devoted to the knowledge and mastery of the external world.

Paracelsus (b. 1493 – d. 1541) and his student Van Helmont (b. 1577 – d. 1644) advocated for an early prototype of psychotherapy; their contribution endowed disease with a body, as they thought of it as a parasite, attributing its causes to external factors independent of Man (VON DEN KRANKHEITEN SO DIE VERNUNFFT BERAUBEN, 1567). Van Helmont, in particular, opposed the old Hippocratic theory of diseases as catarrhs, as fluxes from the brain to which vapours had ascended. He spoke of the spina, the thorn, i.e. irritations, of a form in which maladies acted upon the body. William Harvey (b. 1578 – d. 1657), in his embryological work thought of tumours as leading a life of their own, and of diseases from poison or contagion as also holding their own form of vitality (DE MOTU CORDIS, 1628). Thomas Hobbes had already espoused his naturalistic conception of man in which Man’s soul is assimilated into the physiology of the brain and nervous system (DE CORPORE, 1655; DE HOMINE, 1656). A work of the physician La Mettrie (L'HOMME MACHINE, 1748), inspired by Descartes, sanctioned the extension of automatism to include thought (res cogitans). When the empiricist John Locke maintained (ESSAY CONCERNING HUMAN UNDERSTANDING, 1690) that all ideas come from experience, Leibniz, the epiphenomenal rationalist, answered (NOUVEAUX ESSAIS SUR L'ENTENDEMENT HUMAIN, 1714) that intelligence is always a necessary precondition for every experience. The question in point was basically one of knowing if, and to what extent, reason could dispense with direct observation of facts concerning external reality. Locke's influence, which was very great in France in the eighteenth century, had a particularly strong effect on Condillac (ESSAI SUR L'ORIGINE DES CONNAISSANCES HUMAINES, 1746). In Great Britain, Locke's empiricism paved the way for David Hume's theories of neutral monism (AN ENQUIRY CONCERNING HUMAN UNDERSTANDING, 1748), which brought to light the role that repetition and habit played in acquiring knowledge. The theories of John Stuart Mill, author of an associationist system which was to have great repercussions on the continental philosophies (THE AUTOBIOGRAPHY, 1873). In the meantime, the philosopher Immanuel Kant had cut through the Locke-Leibniz debate by revolutionizing the epistemological problem (KRITIK DER REINEN VERNUNFT, 1781). When Kant demonstrated that knowledge is necessarily the result of a synthetic activity of the mind, his critics attacked certain illusory ideas pertaining to spiritual substance, such as the soul or God. Kant’s Critiques thus undermined that ontological psychology which Christian Wolff (PSYCHOLOGIA RATIONALIS, 1734) maintained, in keeping with the prevailing current of theologico-philosophical thought in Europe, still superimposed on an empirical psychology, which he held to be valid on the level of sensory experience (PSYCHOLOGIA EMPIRICA, 1732). Though repudiated by Kant in the domain of knowledge, the value of sensibility (Fr. le sens intime) was reaffirmed by Maine de Biran (b. 1766 – d. 1824) and by the protagonists of the French eclectic school including Victor Cousin, Royer-Collard, and Théodore Jouffroy. Sensibility and introspection remained the surest basis for psychology, which they continued to regard as that part of philosophy whose goal was the study through direct consciousness of the soul and its aptitudes. In Germany, the Kantian condemnation of metaphysics did not prevent it from re-emerging, but rather supplied metaphysics with the impetus and the motives for an unusually vigorous renewal through such illustrious figures as Fichte, Schelling, Hegel and Schopenhauer, who, together, breathed new life into the old form of Leibniz’s notion of an unconscious agency of mind. It is noteworthy, parenthetically, that despite their quasi-pantheism the Romantic Movement was not necessarily anti-Scientific. What can be said is that the Romantics were opposed to a certain kind of mechanical science, and that they were divided as to whether the mechanical inventions of Man took away from the aesthetic beauty found in nature. However, a not inconsiderable number of romantics, including Schelling, who had come to hold the post of secretary of the Academy of Sciences at Munich, and Maine de Biran, who admired the physicist Ampère, eagerly followed the latest developments in natural science. Others also undoubtedly contributed positively to the advancement of science through their bold speculations - especially in biology and the psychology of the Unconscious. One thinks again of Schelling - who postulated his natural philosophy and its counterpoint ‘identitätsphilosophie’ (IDEEN ZU EINER PHILOSOPHIE DER NATUR ALS EINLEITUNG IN DAS STUDIUM DIESER WISSENSCHAFT, 1797) - a creative, dynamic, evolutionary substratum of nature which achieved its goal in man himself, or of C. G. Carus (VORLESUNGEN ÜBER PSYCHOLOGIE, 1831; PSYCHE,1846; ZUR ENTWICKLUNGSGESCHICHTE DER SEELE, 1851), or of Heinrich von Schubert - Schelling’s colleague at the University of Erlangen and translator of Erasmus Darwin - who had investigated the symbolic language of dreams or, as he so concisely put it ‘the night-side of science’ (SYMBOLISM OF DREAMS, 1814).

The Last Exorcist – Gassner and Mesmer

The decisive impulse toward the fullest elaboration of dynamic psychiatry has been said to begin with the clash between two paradigms; that is to say, the defeat of established religious practice, in the guise of Johann Joseph Gassner (b. 1727 – d. 1779), and Enlightenment thought, brought to the foreground by Franz Anton Mesmer (b. 1734 – d. 1815) (see Henri Ellenberger’s, THE DISCOVERY OF THE UNCONSCIOUS: THE HISTORY AND EVOLUTION OF DYNAMIC PSYCHIATRY, 1970).The life of Gassner is not well documented – although his reputation as the most celebrated exorcist of his age is unquestionable. Gassner was born in Braz, a small village in the mountains of western Austria. He was ordained into the priesthood of the Catholic Church in 1750. His ministry began in 1758 from the small village of Klösterle in eastern Switzerland. A few years later, it is said, he had begun suffering from violent headaches and dizziness whenever he began to celebrate mass, preaching, or hearing the confessions of his parishioners. Gassner was led to ascribe the illness to a single suspect – the Evil One. He is said to have resorted to exorcism and prayer, and his troubles eventually disappeared. Enlivened by this response to his own ailments Gassner turned his attention to his parishioners. He began to exorcise the sick, seemingly with much success. So much so that patients began to call upon his services from the neighbouring districts. In 1774, his fame greatly increased after he successfully cured the aristocrat Countess Maria von Wolfegg. Moreover, in that same year Gassner published a pamphlet in which he distinguished two types of illness: one that belonged to Nature and, thus, physicians, and one that was preternatural, and belonged to the auspices of the Church. The latter illness he divided into three categories: circumsessio (an imitation of natural illness caused by the Devil), obsessio (the effect of sorcery), and, possessio (overt diabolical possession). In all cases, Gassner told the patient that their Faith would dictate whether any cure would be possible. It is then that Gassner asked of his patient whether he might perform the exorcismus probativus (trial exorcism). If the symptoms were made manifest from the outset of prayer – which he termed the crisis – then, Gassner assumed, it was proven beyond doubt that the disease was preternatural and caused by the Devil. If no symptoms appeared at the outset, then Gassner sent the patient to a physician. Gassner, at least according to his own measure, can be suggested to have considered his actions beyond reproach from the orthodoxy of the Church and from the medical establishment of the time. Between November 1774 and June 1775 Gassner was appointed to an honorary position in the court of Prince Bishop of Regensburg, and thus, took up residence in the church town of Ellwangen. During this time Gassner’s treated hundreds of people and his fame soured – large numbers of pamphlets for, and as many against, Gassner’s methods were written and distributed in Austria, Germany, Switzerland, and France. Gassner was famous – however, he had also succeeded in dividing Europe.

At this time Vienna was the seat of the Austrian monarchy and the Austro-Hungarian Empress. It proudly stood for the rights of hereditary status and position – the high-born were born to rule, the low-born were born to be ruled over. Vienna, though, was also an artistic and scientific centre of the highest intellectual standing; enabled, not least, by the vast wealth of its Imperial patron. The new rationalism of the Enlightenment - which proclaimed the primacy of reason over ignorance, superstition and tradition – had not just found powerful allies within the Imperial court of Maria Theresa of Austria, it had also hugely powerful friends in the courts of Frederick II of Prussia and Catherine the Great of Russia. These Imperial courts of Europe sponsored the widest possible dissemination of the new enlightened thinking; those politically minded enough who stood in opposition to this shift in power were wise to lower not just their eyes, but also, the extent to which they went about practicing their traditional beliefs. By May 1775 Gassner was under suspicion, an inquiry into his methods had ordered him to restrict his activities to patients who had been referred by other priests. The instigator of this first inquiry was the University of Ingolstadt. In a politically motivated response, his patron, the Prince Bishop of Regensburg, cousin to the Empress Maria Theresa, mounted his own inquiry which also found against Gassner. Gassner, it may be said, was a marked man. His fame had gotten him into a serious dilemma – he was now a pawn at the mercy of the growing tensions and conflict between the two great powers; the throne of the Vatican and the Imperial thrones of Europe. The worst was far from over for Gassner. In Munich, another inquiry commission was appointed by royal decree. This time, Prince Max Joseph of Bavaria, invited a certain Dr. Franz Mesmer to head an investigation of Gassner’s methods.

Mesmer had been travelling the Rhine and Constance, where he had claimed to have performed marvellous cures by means of his new principle – he called it animal magnetism. Mesmer arrived in Munich on 23rd November 1775, and to the obvious delight of his sponsors proceeded to demonstrate the appearance and disappearance of various symptoms, even convulsions, with nothing more than the touch of a finger. The following day, 24th November, Mesmer provoked an epileptic into attack and then claimed to be able to cure the patient through the use of his animal magnetism. In effect, then, Mesmer had duplicated Gassner’s method without recourse to the use of exorcism. Mesmer declared that Gassner was undoubtedly an honest man, however, he also added, that Gassner must, albeit without knowledge of doing so, treat his patients using animal magnetism. Fr. Gassner was not permitted to observe these demonstrations or a right to reply to Mesmer’s findings. At the same time as Mesmer’s demonstrations of animal magnetism in Munich a communiqué was sent from the Empress Maria Theresa of Austria to the Prince Bishop of Regensburg requesting his dismissal. The Prince Bishop submitted to this request, and Gassner was sent to live out his days in the obscurity of a community in Pondorf. In the Vatican, Pope Pius VI (Giovanni Angelo Braschi) also ordered an investigation of Gassner’s activities. In addition, in the papal decree that followed this investigation, it was stated that while exorcism was a common a salutary practice of the Church, it was to be performed with discretion and with strict adherence to Roman Catholic ritualistic prescription. Fr. Gassner died on 4th April 1779 – his lengthy epitaph describes him as the most celebrated exorcist of his time. It can be said that no-one ever doubted Gassner’s piety, his humble manner, or the selflessness of his chosen work, however, to his cost he had found that curing the sick was not enough; one must cure them with methods acceptable to the prevailing authorities. Gassner remains the last great exorcist; it was from 1775 onwards, which marks the shift in authority from the forces of tradition to the forces of reason in Europe.

Discipleship - Mesmer and Puységur

Franz Anton Mesmer had married well in 1767 - Maria Anna von Posch was a wealthy widow of noble descent (see Henri Ellenberger’s, THE DISCOVERY OF THE UNCONSCIOUS: THE HISTORY AND EVOLUTION OF DYNAMIC PSYCHIATRY, 1970). Mesmer was a refined and cultured man of the arts and sciences. Friends who visited his home included Haydn and the young Mozart. Indeed, Mozart’s earliest opera, BASTIEN UND BASTIENNE, had its first known performance in Mesmer’s private theatre. Mesmer had been educated in theology, philosophy and medicine. His medical dissertation had been on the influence of the planets on human diseases (DE PLANETARUM INFLUXU IN CORPUS HUMANUM, 1766). He was awarded his doctorate for this work. During 1773 and 1774 Mesmer began treating a twenty-seven year old female patient called Fräulein Oesterlin. This fräulein has presented to Mesmer with no less than fifteen separate symptoms. He studied her symptoms with particular reference to their astronomical periodicity, and sought to change the symptoms through the use of magnets, he called this an artificial tide. Thus, after making Fräulein Oesterlin swallow a prepared solution containing iron, he attached three magnets to her body. His patient claimed to feel extraordinary streams of fluid running downward through her body, and, reported that she was cured of all symptoms for several hours after this event. Mesmer espoused that these results could not possibly be caused by magnets alone, rather, that the results obtained from ‘an essentially different agent.’ That is, these magnetic streams were produced by what he later came to call animal magnetism. The magnets merely served to direct the animal magnetism around the body of his patient. Mesmer noted the date of his discovery to 28th July 1774. Fräulein Oesterlin made a full recovery, and later married Mesmer’s step-son. Then, in June 1775, Mesmer was invited to the home of Baron Horeczky de Horka. The Baron was suffering from nervous spasms which were persistent despite the efforts of Vienna’s top physicians. For six days the Baron’s condition ebbed and flowed between health and illness, until, on the seventh day, his condition became intolerable and he asked Mesmer to cease his treatment – Mesmer dutifully stopped, and packed his things in preparation to leave the castle, but not before, at the last minute, healing a deaf man outside the gates of the castle who had lost his hearing some six weeks before. It was from this trip that Mesmer went directly to Munich to challenge Gassner’s method. When he returned to Vienna, he did so as a newly elected member of the Bavarian Academy of Sciences. Back in Vienna, Mesmer took on many new cases most famously perhaps that of a blind girl with prodigious musical talents called Maria Theresia Paradis. Maria Paradis was eighteen years old, and had been blind since the age of three and one half. Interestingly, some two years later, in late 1777, Mesmer was to leave both his wife and Vienna; his detractors are said to have claimed an affair had taken place between Mesmer and Maria Theresia Paradis. Mesmer never saw his wife again. It may be suggested that the close proximity and developing rapport between patient and doctor had engendered something akin to Freud’s later theory of transference. Mesmer arrived in Paris in February 1778, and it would appear that he was extremely eager to form contacts within all the major scientific bodies: Académie des Sciences, Société Royale de Médecine, Faculté de Médecine. By the year 1781, Mesmer had dispensed with magnets due to the massive demand for his treatments and began collective or group treatments. He instigated group treatments under the name of the baquet. Mesmer doctrine of general fluid [gravitatio universalis] was accompanied by Gassner’s theory of crisis. Here, then, the crisis was viewed in much the same way as Gassner had viewed the first steps in his method of exorcism. That is, for Mesmer and Gassner, the crisis was the artificially produced evidence of a disease or illness and it also represented the means of cure. The English physician John Grieve visited Mesmer in Paris during May 1784 and reported that; “there were never less than two hundred patients at one time.” However, two months prior to Grieve’s visit, Mesmer had himself begun to suffer from the same infamy as Gassner had attracted in 1775.

In March 1784, The King of France had requested two commissions of inquiry consisting of members from the Académie des Sciences, Société Royale de Médecine, and the Faculté de Médecine. The point in question was not whether Mesmer had cured his patients, but rather whether Mesmer had the right to claim to have discovered a new physical magnetic fluid. The outcome was not good for Mesmer and his growing band of disciples. The commission’s conclusions were broadly disseminated that no evidence at all existed to corroborate Mesmer claim of physical fluid – although the possibility of therapeutic effects were not denied, and were ascribed to the ‘imagination’ of the patients. Moreover, a confidential report intended only for the King would appear to have suggested the dangers resulting from an erotic attraction upon magnetised female patients by their male magnetisers. Just when Mesmer’s fortune appeared to be at its lowest ebb more ridicule was poured upon him. The famous Parisian scholar Court de Gébelin had written a glowing report on Mesmer and his method, claiming in his pamphlet that Mesmer had cured him of his ailments. Unfortunately, Gébelin relapsed, and died at Mesmer’s home. Now it was not just his critics who were becoming increasingly animated, Mesmer’s own training institution, which he called the Société de l’Harmonie – a strange melange of business, school and Masonic lodge – also, began to split from their mentor and teacher. Many members of the society had become disillusioned and disaffected by Mesmer’s grandiosity and egocentrism. The last straw, so to speak, came when his most loyal disciple, a certain Amand-Marie-Jacques de Chastenet, Marquis of Puységur (b. 1751 – d. 1825), though espousing his loyalty to Mesmer’s teaching, discovered something which would shift the history of mesmerisation; it was called magnetic sleep. Mesmer could take no more of Paris life; he left at the beginning of 1785. The movement he founded had begun to develop in a new direction under Puységur. Mesmer wandered through Switzerland, Germany and France. In 1793, he returned to Vienna – but he was expelled as ‘politically suspect.’ Many years later, in 1812, a physician called Wolfart chanced upon Mesmer and found to his surprise that Mesmer had taken on all the trappings and characteristics of a German aristocrat – he had also taken to speaking exclusively in French, as was their custom. The grandiose self-publicist and professional charmer had, it seems, finally retreated into a caricatured persona of his own design and affectation. Mesmer died in Meersburg, on the shores of Lake Constance, it was 5th March 1815. His lasting legacy may be conceived in three main ways: firstly, he gave us the still commonly used term mesmerised, secondly, he established the principle that the therapeutic agent of cure is the therapist/doctor themselves – through the use of both rapport and the crisis, and lastly, he grouped his disciples together into a society which taught them his doctrine, discussed their application, and maintained a unity of therapeutic method.

Magnetic Sleep - Puységur

Amand Puységur was the eldest of three brothers, all of which had become devoted followers of Mesmer (see Henri Ellenberger’s, THE DISCOVERY OF THE UNCONSCIOUS: THE HISTORY AND EVOLUTION OF DYNAMIC PSYCHIATRY, 1970). He had formerly distinguished himself as an artillery officer at the siege of Gibraltar. He appears to have divided his life between his military duties and his immense ancestral estate in Buzancy near Soissons. One of Puységur’s earliest patients, a servant whose family had been in the service of the Puységur family for several generations, was called Victor Race. Victor suffered from a mild respiratory disease, but when magnetised he presented a very peculiar crisis. Victor did not convulse, and nor did he exhibit strange movements; it was as if he had fallen into a strange kind of waking sleep in which he appeared to be more alert and aware than in his ‘normal’ waking state. Puységur reproduced this strange sleep a number of times before successfully trying the same method on other patients. Puységur found that by producing this special type of crisis he was able to diagnose their diseases, predict its course (which he called pressensation), and tender an appropriate diagnoses and prescription. The analogy between magnetic and natural somnambulism (sleep walking) was soon recognised, and thence the name given to this artificially reproduced somnambulism was given as artificial somnambulism (only much later was Braid (1842) to term hypnosis). It was also through working with Victor that Puységur also learnt of another interesting use for artificial somnambulism, namely, he found that Victor was very much more receptive to suggestions made whilst in this state and upon awaking was much better able to implement these new life choices. In 1785, Puységur took Victor to Paris to demonstrate the strange sleep – but, Victor’s health deteriorated rapidly after numerous demonstrations and public humiliation. It is considered thus that Puységur decided forthwith to restrict the use of magnetism and the perfect crisis to purely therapeutic purposes; deciding never to use the method for the mere entertainment of others. In Strasbourg, Puységur assembled the elite aristocracy of Alsace into his own society; it was called the Société de l’Harmonie des Amis Réunis. By 1789, Puységur count upon more than two hundred followers and practitioners. Then came the French Revolution of 1789 – one can only surmise what would have transpired for Puységur’s and his society of lay-physicians had not so many of their aristocratic number emigrated or been sent to the scaffold. Puységur, it seems, spent two years in prison. After which he was able to take back his ancestral home and later become Mayor of Soissons. He went on to write literary work, but mostly his time was taken with his research into the application of artificial somnambulism and suggestion. He investigated the hypothesis that severe mental illness might be a type of somnambulistic distortion, and that his methods might be useful in the treatment of the ‘insane.’ In the evening of his life Puységur had become the respected patriarch of the magnetisers – that is, the lay-physicians. He went on to investigate the application of treatment to a young boy, Alexandre Hébert, who suffered from episodes of terrific rages, extreme outbursts and violence; it has been said that Puységur spent six months attempting to cure the young boy, never leaving the boys side during all that time. Here, one can be drawn to the comparison between Puységur and the very much later prototypical model for treatment adopted by psychotherapists working with clients with acute psychoses. Amand, Marquis de Puységur died on the day of Charles X coronation at Reims Cathedral on 29th May 1825. Puységur was seventy-four years old. Charles Richet rediscovered the life and work of Puységur in 1884, and he went on to show that most of what his illustrious contemporaries believed to have been discovered in the field of hypnosis was already contained in the body of Puységur’s writings.

Biological psychiatry

The narrative inheritance obtaining from Christianity, humanism, and rationalism was variegated. A growing belief in materialism, however, bolstered by a positive belief in a mechanistic clock-work universe, led medico-psychologists to abandon thoughts of daemonic possession or transcendental intervention; the aetiology of mental illnesses lay in the body, and, as such, its causes were organic. To the somatic backdrop of physiology and iatrophysics emerged the figure of William Cullen (b. 15th April 1710 – d. 5th February 1790), who espoused a Lockean psychological paradigm of mental illness (FIRST LINES OF THE PRACTICE OF PHYSIC 1777; A TREATISE OF THE MATERIA MEDICA, 1789). Cullen held that the precipitating cause of mental illnesses had its aetiology in acute cerebral activity, that is, excessive irritation of nerves – for Cullen, then, insanity was a nervous disorder. He coined the term ‘neurosis’ to describe any illness obtaining from an inequality of excitation within the nervous system. Cullen’s import can be said to lay in the fact that he, alongside his philosophical friend David Hume, held that sense impressions and associations of ideas are basic to all intellectual processes. Therefore, distorted sense and distorted associations of ideas were mental disorders grounded within a dynamic neurophysiological frame. Cullen, it has been said, reintegrated the mental back into the somatic discourses on madness. After 1770 much published work had begun to emerge from the observation of patients within the privately run madhouses, and not just the containment of patients by such establishments. This shift in emphasis from the physical to the psychical may also be suggested to have been brought about, in no small part, due to the popularisation brought to the subject of madness by George IIIs own bout of illness from 1788 to 1789. Alexander Crichton’s homage to Locke (AN INQUIRY INTO THE NATURE AND ORIGIN OF MENTAL DERANGEMENT, 1798), similarly argued that medico-psychology should be based upon the philosophy of mind. At this time the Florentine physician Vincenzo Chiarugi (b. 17th February 1759 – d. 22 December 1920) published a major three volume work (LA FOLLIA, 1793-4). Chiarugi espoused theories that bodily states influenced the mind via the activities of the sense and the nervous system. He theorised on the ‘sensorium commune’ as mediating between the intellect and the senses, between soul and body. Chiarugi, it can be said, appears to have offered an early psycho-physiological solution to Cartesian dualism (substance dualism). Moreover, on the aetiology of mental conditions Chiarugi followed the Enlightenment view that such conditions were acquired not inherited; as such, he held out hope for a humane medical cure, not just any enforced medical cure. Furthermore, as we can see, the end of the nineteenth century brought with it not just a shift toward a psychological model for mental illnesses, but also, and perhaps more interestingly, a humano-reformist movement as well. These reformers, viewed the mad just as human as themselves; and moral control and humane management, rather than the use of force, offered a superior model of efficacy to treatment. That is, the physician’s character, expertise and moral example had a vital part to play in any potential cure of patients with mental disorders.

In Paris, the physician Philippe Pinel (b. 20th April 1745 – d. 25th October 1826) instigated humane medico-psychological approaches at both of the largest institutions in France: the Bicêtre and the Salpêtrière. Pinel stressed the importance of the psychogenic evidence at hand; post mortem examination of the brains taken from the insane failed to produce evidence of structural abnormalities (MÉMOIRE SUR LA FOLIE, 1794; NOSOGRAPHIE PHILOSOPHIQUE OU MÉTHODE DE L'ANALYSE APPLIQUÉE À LA MÉDECINE, 1798; TRAITÉ MÉDICO-PHILOSOPHIQUE SUR L'ALIÉNATION MENTALE; OU LA MANIE, 1801). Moreover, Pinel was considered a great clinical, that is to say, he was a moral optimist at heart – he held that although brain damage may not be cured, functional disorders like melancholia and mania were responsive to treatment. Following Pinel’s example, Jean-Etienne Dominique Esquirol (b. 1772 – d. 1840), asserted that although ultimately organic in nature, psychiatric disorders were disorders with psycho-social causes. In his major work, MALADIES MENTALES (1838), Esquirol delineated partial mental conditions (mono-mania) associated with affective disorders, such as, pyromania, kleptomania, and nymphomania. Esquirol effectively changed the classification of mental disorders through the use of the data accumulated from the new ‘observation-based’ model for asylums.

Jean-Martin Charcot (b. 29th November 1825 – d. 16th August 1893), Clinical Professor of the Nervous System at the Salpêtrière, became the most famous exponents of the burgeoning humano-psychiatric movement. His clinic became the European focal point for neurologists and psychiatrists alike. Charcot’s most famous work (LEÇONS SUR LES MALADIES DU SYSTÈME NERVEUX, 1871) brought with it a much needed dose of clarity to the debates on nosology (i.e. diagnostic categorisation) regarding certain neurological disorders which overlapped with the domain of medico-psychology. Charcot was to become an aristocratic within psychiatric circles, not least because of his firm belief in clinical observation and solid grasp of methodical research. His most famous work was not, contrary to popular opinion, on the hypnosis of the subject of hysteria, he was, rather, a passionate neurologist committed to the application of patho-anatomical techniques that brought order to the then chaos of symptomology.

Contemporaneously, in pre-unified Germany, the university research model for medical establishments was used. It has been said that this association was a major factor in the bitter disputes which raged for decades between the organic and psychological camps. In Germany, then, at the beginning of the nineteenth century, it was Johann Christian Reil (b. 20th February 1759 – 22nd November 1813) who first coined the word ‘psychiaterie’ in 1808. Reil was to develop a holistic approach which was much indebted to the tradition of Romanticism. In his work (RHAPSODIEN AUF DEN EINSATZ PSYCHOLOGISCHER BEHANDLUNGSMETHODEN IN NERVENZUSAMMENBRUCH, 1803), Reil proposed an idiosyncratic twist on the theme of humane treatment where the clinician would use psychodrama (play-acting) to break the irrational beliefs of the mental patients, whilst, at the same time, reinforcing the destruction of irrational beliefs through, for example, the use of boiling wax on the palm of the hands, or immersion in a tub filled with live eels. The Viennese anatomist Franz Joseph Gall (b. 1758 – d. 1828) and J. C. Spurzheim (b. 1776 – d. 1832) can be said to also have added fuel to the fiery debates concerning organic and psychological causation (ANATOMIE ET PHYSIOLOGIE DU SYSTÈME NERVEUX EN GÉNÉRAL ET ANATOMIE DU CERVEAU EN PARTICULIER, AVEC DES OBSERVATIONS SUR LA POSSIBILITÉ DE RECONNOÎTRE PLUSIEURS DISPOSITIONS INTELLECTUELLES ET MORALES DE L'HOMME ET DES ANIMAUX, PAR LA CONFIGURATION DE LEURS TÊTES, 1810; DISCOURS D'OUVERTURE, LU: À LA PREMIÈRE SÉANCE DE SON COURS PUBLIC SUR LA PHYSIOLOGIE DU CERVEAU, 1808; DES DISPOSITIONS INNÉES DE L'ÂME ET DE L'ESPRIT : DU MATÉRIALISME, DU FATALISME ET DE LA LIBERTÉ MORALE, AVEC DES RÉFLEXIONS SUR L'ÉDUCATION ET SUR LA LÉGISLATION CRIMINELLE, 1811; RECHERCHES SUR LE SYSTÈME NERVEUX EN GÉNÉRAL, ET SUR CELUI DU CERVEAU EN PARTICULIER; MÉMOIRE PRÉSENTÉ À L'INSTITUT DE FRANCE, LE 14 MARS, 1808; SUIVI D'OBSERVATIONS SUR LE RAPPORT QUI EN À ÉTÉ FAIT À CETTE COMPAGNIE PAR SES COMMISSAIRES, 1809; SUR LES FONCTIONS DU CERVEAU ET SUR CELLES DE CHACUNE DE SES PARTIES. AVEC DES OBSERVATIONS SUR LA POSSIBILITÉ DE RECONNAITRE LES INSTINCTS, LES PENCHANS, LES TALENS, OU LES DISPOSITIONS MORALES ET INTELLECTUELLES DES HOMMES ET DES ANIMAUX, PAR LA CONFIGURATION DE LEUR CERVEAU ET DE LEUR TÊTE, 1822-25). In their view the ‘science’ of phrenology held the answer to questions concerning localisation of cerebral function; to phrenologists the seat of the mind was the brain and the structure of a determined personality. Here, the brain was seen as a cluster of ‘organs’ (destructiveness, love of children, benevolence, etc.), where each occupied a specific cortical area. The size of these organs dictated to a lesser of stronger degree the personality trait. Put simply, the bumps upon a person’s head were thought to determine their personality traits. Moreover, this seemingly simplistic understanding for investigating the personality lent itself rather well as a digestible form that the general public could swallow. Alienists (as was the given name for those who worked with the insane), as well as the general public, made phrenology a commonplace talking point in European households. However, the medical establishment did not share this enthusiasm – the talented anatomist Gall was barracked into leaving his beloved Vienna in 1805. The somatists’ response was not long in coming. Led by Maximilian Jacobi (b. 1775 – d. 1858), and fixed by J. B. Friedreich’s ATTEMPT AT A HISTORY OF LITERATURE OF THE PATHOLOGY AND THERAPY OF PSYCHIC ILLNESSES (1830), somatic psychiatry was in the ascendancy. However, the boldest advocate of somatic psychiatry was to become Wilhelm Griesinger (b. 29th July 1817 – d. 26th October 1868). In his work (PATHOLOGY AND THERAPY OF PSYCHIATRIC DISEASES, 1845), Griesinger boldly states that ‘mental diseases are brain diseases.’ And he is famously quoted as frequently telling his students, ‘every mental disease is rooted in brain disease.’ Nevertheless, although Griesinger could not prove his assertion, the conviction of his assertion spurred many into the scientific investigation of this claim. Furthermore, Griesinger’s claims may also be suggested to have, in some small way, restored dignity and reduced the stigmatisation attached to a diagnosis of lunacy – it was a legitimate disease, and a scientist had said so. Griesinger, a Professor of Psychiatry in Berlin with much influence, also held that mental diseases were progressive – that is, to his thought, mental states worsened from depressive states into more disordered conditions. For Griesinger, then, a somatic abnormality began with excessive cerebral irritation, moved into chronic irreversible brain degeneration, and ended in the situation of disintegrated ego common in dementia. This longitudinal descent – from normal to pathological psychic processes – was to be later adopted by Kraepelin. After 1850, university psychiatry flourished partly due to the framework installed by such figures as Wilhelm Griesinger. It is Griesinger’s call for psychiatry and neurology to combine forces (pace Charcot in Paris) that appears to have galvanised the clinics and research institutes of Germany into producing equally eminent practitioners as the French. Again, the methodology used in research held to the ‘scientific’ model – systematic observation, experimentation, and dissection. Although, as we have already seen, as Pinel had already cautioned; dissection of insane brains had not yet produced any evidence of structural abnormality. That said, a product of the academic system established by Wilhelm Griesinger in Berlin, later to become the influential Professor of Psychiatry in Vienna, was Theodor Meynert (b. 1833 – d. 1892). Meynert specialised in the microscopic technique of investigating the relationship between the central nervous system, the brain cortex, and the cerebrum. He formulated and demonstrated how certain nerve cells communicated with other nerve cells along neural pathways. However, his somatic credentials did not forestall his psychological ambitions from emerging – in later life Meynert proposed a psychological theory based upon purely hypothetical entities, such as, the primary and secondary ego to account for behavioural and cognitive disorders (PSYCHIATRIE. KLINIK DER ERKRANKUNGEN DES VORDERHIRN, 1884). Meynert’s arguably finest pupil was Carl Wernicke (b. 1848 - d. 1905). As a somatist his all-consuming passion was the cerebral localisation of aphasia (speech and language disorders) (TEXTBOOK OF BRAIN DISORDERS, C.1881-3). Wernicke discovered that when patients suffered a stroke in the posterior (perisylvian) brain, they lost the ability to speak or understand words. ‘Wernicke’s aphasia’, as it became known, corresponded to a part of the brain we still call ‘Wernicke area.’ Wernicke findings gave considerable weight to the concept of cerebral dominance.

An unhealed wound – Freud and Kraepelin

At the end of the nineteenth two psychiatrists began to take up scholarly arms for the cause of the future of psychiatry: one was Austrian, and he fought on the side for an inductive approach to psychology and psyche; the other was German, and he fought on the side for empirical psychophysi-ology and soma. To these men of immense scholarship and learning, the battles of the past, like those between Mesmer and Gassner, psyche and soma, medicine and mind, had left an unhealed wound. Both men were ambitious and talented enough to take on the problematic of the final solution, each in their own dogmatic way. Moreover, it is not too bold to say that both men would come to dominate the paradigm of psychiatric thought for the twentieth century.Emil Kraepelin (b. 15th February 1856 – d. 7th October 1926) is specifically credited with the classification of what was previously considered to be a unitary concept of psychosis into two distinct forms: manic depression (bi-polar and uni-polar depressive disorder) and Dementia praecox (schizophrenia). Drawing on his long-term research, and using the scientific criteria of observation, outcome and prognosis, he developed the concept of dementia praecox, which he defined as the “sub-acute development of a peculiar simple condition of mental weakness occurring at a youthful age” (LEHRBUCH DER PSYCHIATRIE, 1893) When he first introduced this concept as a diagnostic entity in the fourth German edition of his textbook of psychiatry, it was placed among the degenerative disorders alongside, but separate from, catatonia and dementia paranoides. At that time, the concept largely corresponded with Ewald Hecker’s view of hebephrenia. However, by the sixth edition of the TEXTBOOK OF PSYCHIATRY (1899) all three of these clinical types are treated as different expressions of one disease, dementia praecox. The guiding principle of his method was the recognition that any given symptom may appear in virtually any one of these disorders; that is, there is almost no single symptom occurring in dementia praecox which cannot sometimes be found in manic-depression. What distinguishes each disease symptomatically, as opposed to the underlying pathology, is not any particular symptom or symptoms, but a specific pattern of symptoms. In the absence of a direct physiological or genetic test or marker for each disease, it is only possible to distinguish them by their specific pattern of symptoms. Therefore, Kraepelin's system is a method for pattern recognition, not a grouping by common symptoms. Kraepelin also demonstrated specific patterns in the genetics of these disorders and specific and characteristic patterns in their course and outcome. Generally speaking, there tend to be more schizophrenics among the relatives of schizophrenic patients than in the general population, while manic-depression is more frequent in the relatives of manic-depressives. He also reported a pattern to the course and outcome of these conditions. Kraepelin believed that schizophrenia had a progressive course in which mental function continuously (although perhaps erratically) declines, while manic-depressive patients experienced a course of illness which was intermittent and cyclic; that is, one where patients were relatively symptom-free during the intervals which separate acute episodes. This finding led Kraepelin to name dementia praecox (the dementia part signifying the irreversible mental decline, praecox to signal the premature nature of this decline). It later became clear that dementia praecox did not necessarily lead to mental decline, and so was renamed by Eugene Bleuler (b. 30th April 1857 – d. 9th February 1940) to correct the misnomer; he term he chose was schizophrenia. Kraepelin postulated that there is a specific brain or other biological pathology underlying each of the major psychiatric disorders. As a colleague of Alois Alzheimer (b. 14th June 1864 – d. 19th December 1915), and co-discoverer of Alzheimer’s disease, it was Kraepelin’s laboratory which discovered its pathologic basis. Kraepelin was confident that it would someday be possible to identify the pathologic basis of each of the major psychiatric disorders. Kraepelin’s great contribution in ‘discovering’ schizophrenia and manic-depression remains relatively unknown to the general public, and his work, which had neither the literary quality nor paradigmatic power of Freud’s, is not widely read outside scholarly circles. Kraepelin’s contributions were to a good extent marginalized throughout a good part of the twentieth century. However, his views now dominate psychiatric research and academic psychiatry, and today the published literature in the field of psychiatry is overwhelmingly biological and genetic in its orientation. His fundamental theories on the aetiology and diagnosis of psychiatric disorders form the basis of the two major diagnostic systems in use today, namely, the American Psychiatric Association’s DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (DSM) and the World Health Organisation’s INTERNATIONAL STATISTICAL CLASSIFICATION OF DISEASES AND RELATED HEALTH PROBLEMS (ICD). Kraepelin’s significance can be said to be not only historical, but contemporary scientific psychiatry is still largely based on his findings and theories of mental illnesses.

Freud & Beyond

“The violent primal father had doubtless been the feared and envied model of each one of the company of brothers: and in the act of devouring him they accomplished their identification with him, and each one of them acquired a portion of his strength. The totem meal, which is perhaps mankind’s earliest festival, would thus be a repetition and a commemoration of this memorable and criminal deed, which was the beginning of so many things—of social organization, of moral restrictions, and of religion.” (Freud, TOTEM & TABOO, 1913).

In the mid-nineteenth century, a period where there were passing references to the cathartic value of talking cures in the treatment of emotional problems, the English psychiatrist Walter Cooper Dendy first introduced the term psycho-therapeia in 1853. Famously, however, it was Sigismund Schlomo Freud (b. 6th May 1856 – d. 23rd September 1939) from Freiberg, Moravia, in what is now the Czech Republic, and his friend and colleague Josef Breuer’s patient ‘Anna O’ [Bertha Pappenheim] who first coined the notional term “talking cure” to account for the dialectical method employed by her analysts. Freud continually developed Psycho-analysis from 1895 through to his death in 1939, and made profound contributions to the field of psychological therapies with his descriptions of: unconscious processes; infantile sexuality; the use of dreams; clinical technique; and his topographical and structural models for the human psyche.

Breuer & Freud’s early work with neurotic female patients had led him to believe that mental illnesses (neuroses) were the direct result of keeping thoughts, ideas, images and representations out of consciousness (STUDIEN ÜBER HYSTERIE, 1985). That is, that these ideas, images and representations had been repressed and were thus clearly unconscious to us. For Freud, the technique of treatment was predicated upon actively listening to the patient’s “free associations” and sustained through providing occasional interpretations and observations on the material shared, which aimed to bring those repressed ideations back into the realm of consciousness, and thus defuse their manifest affects (symptoms). Psychoanalytic theory was the first modern prototype for all of the psychotherapies, and today many schools of psychotherapy continue to define themselves by the ways in which they are different from psychoanalysis. Psychoanalytical psychotherapy is concerned with desires and beliefs and is predicated upon unconscious systems and processes of ‘mind.’ It can be said that psychoanalytic psychotherapy is squarely based on the idea that the return of repressed material lies at the essential level of the human struggle between the needs of the particular individual and the universalising demands of societal culture. In psychoanalysis, one is encouraged to consciously discover these repressed unconscious ideas, thoughts and memories; which, it ought to be added, can be a lengthy and demanding process. Psychoanalysis’ use of free association is the origin of the view of a patient lying on a couch, and where this view derives from, as the relaxed patient is encouraged to vocalise whatever comes into their head, and thus allows their thoughts to find free expression, purgation, and renewed vistas of conscious insight. In this way, the method of free association operates outside the gaze of the patient; which is to say, the therapist does not intrude into the eye-line of the patient. Here, then, the psychoanalytic psychotherapist uses psychoanalytic theory as a scaffolding to confront resistances (ego defences), interpret and reconstruct (reformulate) the patient’s linguistic portrayal of their inner world in a way that may help toward shedding light upon their beliefs and conceptions of and for functioning within the outside world. Freud, the father of psychoanalysis, as well as his colleagues, had noticed that when people with psychological problems were listened to attentively and sympathetically they tended to develop strong positive or negative feelings towards the listener, and the term for this important patterning became transference. Freud and his colleagues, in particular Carl Jung, came to realise that they also developed their own feelings toward their patients – the term given to this patterning became counter-transference – as it became clear that this reaction had a direct bearing upon the working alliance with the patient. Thus, when psychotherapy goes wrong and becomes conceptualised by the patient as abusive, it is considered that the therapist has mismanaged the transference aspect of the therapeutic process. Coupled with psychoanalytic theories of repressed ideations, the theories of transference and counter-transference freighted also a whole new dimension to the work of analysis. There were, however, thinkers who could not agree with the central Freudian thesis that the primary energetic instinctual-reflex (libido) was a sexualised impulsion which was always under all conditions then sublimated in order that the drive-toward-life (Eros) provided by the instinctual-reflex could be energetically invested (cathected) to perform the multitude of actions of everyday life.

Motivated Irrationality

When Wilhelm Dilthey first demarked the fields of empirical natural sciences from those of the interpretive human sciences; that is, history, cultural anthropology, sociology, psychology, and even economics, one assumption remained at the heart of the activity of both the empirical investigation every bit as much as with the interpretative, namely, rationality. One might be drawn to observe that rationality itself appeared to be the very hallmark of the legacy left by positivism and which had come to characterise the Age of Reason. Notwithstanding this emphatic movement, in stark contrast to the succession of positivist paradigms which had privileged reason and rationality, and sought to reasonably explain every human action, a youthful scientist, Freud, began interpreting the actions and motivations of individuals in a way that explained their achievements and gratifications without recourse to a necessarily rational aetiological explanation. Freud’s transition from the study of the brain (soma) to the study of the mind (psyche) had moved him toward a self-analysis whose central thesis was predicated upon the existence of an unconscious aspect to a psyche driven by dynamic instinctual reflexes (Ger. Trieb). However, contrary to the popular misconception that Freud discovered the unconscious, rather it appears that Freud’s medical education was, in fact, steeped within a romantic philosophical tradition. The eminent psycho-historian, Henri Ellenberger (1970), suggests that Freud’s conception of the unconscious ought to be seen as one ‘inseparable’ from the continental traditions in which he had ‘emerged as a reader.’ Which is to say, that the notion and language to account for a dynamic unconscious had gradually emerged from a succession of other thoughts which attached importance to and stemmed from amongst others: Descartes’ MEDITATIONS ON FIRST PHILOSOPHY (1641); David Hume’s complex account for ‘bundles of ideas’; Immanuel Kant’s notion of the thing [of the phenomenal register] and the thing-in-itself [of the noumenal register]; George Hegel’s ‘beyond’ and ‘master-slave dialectic’ PHENOMENOLOGY OF SPIRIT (1807); Arthur Schopenhauer’s ‘Will-to-life’ explored in THE WORLD AS WILL AND REPRESENTATION (1819); Karl Robert Eduard von Hartmann’s first book, THE PHILOSOPHY OF THE UNCONSCIOUS (1869); and not forgetting, of course, the unsettling and provocative systemisation proposed by Friedrich Nietzsche (b. 1844 – d. 1900) through the use of such notions as ‘Eternal recurrence’, the ‘Will-to-power’, and the ‘slave morality.’

The Drives (das Trieb)

As per Schopenhauer and Nietzsche before him, Freud also believed that humans were essentially impelled toward life’s vicissitudes; in other words, they were driven beings. For Freud, however, humankind appeared to be instinctually driven by two conflicting, yet intertwined, rational reflexive factors which led to seemingly irrational manifestations and affects in the social sphere: the Sex drive, also known as the Life drive, that which was called ‘Eros’; and the Death drive, (Ger. Todestrieb) that which Freud’s British biographer, Ernest Jones, called ‘Thanatos.’ Freud’s description of Eros - erotic love - included all creative, life-producing and life-preserving instinctual drives. The Death drive (or Death instinct (see also Freud, S., 1920/1923)) represented an urge inherent in all living things to return to a state of calm, or ultimately, to a state of non-existence or what Barbara Low termed the ‘Nirvana Principle.’ Freud was to give increasing prominence to the presence of the destructive and aggressive Death drive only in his middle and later period, and the contrast between the two represents a revolution in his manner of thinking from the individual psyche to the social psyche.

Psychoanalytic psychotherapy

One can be led quite unnervingly to the thought that historiography resembles the unconscious system in a number of different ways: it is unknown in its fullest extent; if it is held at all then it will most probably be held in a representative moment, or in an otherwise censored formation different and distorted from that of the original. Whatsoever history in-itself might be agreed to represent, ought not the term be inclusive of that which is now without time in the present; thus, representations of imagination and memory we know as the past? And then let us proceed further to surmise that that which we call the past cannot simply be approached, nor representations made to possibly contain it, without some acknowledged censorship or distortion presented in a framing of the original moment. It is here that the value of insight into the depth of our past surely cannot be misguided. Freud, and the participants in his inner circle of ‘ring bearers,’ sought to explore an avenue of thought with revolutionary structural implications for psyche. Through Freud’s Drive/Structure model for mind, and the invention of a language of and for a topography, mechanics, and economical processes for that mind, he may be said to have excavated a concern with the historical landscape beyond our waking consciousness. This representational language, psychoanalysis, as it was first conceived, openly intends to interrupt dysfunctional patterns and affects, explore our needs and desires, and allow for a containment of our dynamic relation with the other. Moreover, it is these psychodynamic thoughts which led to the rise of a critical theory against misconceptions (Fr. Méconnaissance) obtained from an over-privileging of the ontological account for the central importance of “I” (Lat. Ego) in our waking life over that of the self (see also Lacan, ECRITS 1977). This critical thought strikes at the heart of any notions reliant upon a Cartesian primacy for a centred rational consciousness (Lat. Cogito); as that which we entrust to signify and encompass our conception of that part of me known as “I”. That is to say, a criticism which beckons our sensibilities toward not just our dreams, but also toward our waking desires, littered as they are with demonstrations which pointedly suggest an occasional overpowering of our conscious rational life by seemingly irrational expressions of desire. Freud’s mature work (see also Freud, THE EGO AND THE ID, 1923) for some is seen as nothing less than a revolutionary theory indicative of a new Copernican paradigm for the psychological study of the mind; a concern so serious as to hold fast to a psycho-linguistic determination for motivated irrationality, delivered in the style of a meta-narrative which for some, as we shall see, systematically deconstructs of the primacy of Cogito. Of the Freudian impact on the History of Ideas, it may be simply said; whether we argue with him or against him, we cannot argue without him.

Primary and Secondary Processes

In a letter (no. 32) to his friend and confidante, Wilhelm Fliess, dated October 20th 1895, Freud claims that ‘the barriers were suddenly raised, the veils fell away, and it was possible to see through from the details of the neuroses to the determinants of consciousness.’ Freud continues in the same letter:

‘Everything seemed to fit together, the gears were in mesh, the thing gave one the impression that it was really a machine and would soon run of itself. The three systems of neurones, the free and bound conditions of quantity, the primary and secondary processes, the main trend and the compromise trend of the nervous system, the two biological rules of attention and defence, the indications of quality, reality and thought, the state of the psycho-sexual groups, the sexual determination of repression, and finally, the determinants of consciousness as a perceptual function – all this fitted together and still fits together! Of course I cannot contain myself with delight.’However, the editor writes, ‘But the cheerful spell lasted only a short time.’ By November 8th in a letter [no. 35] to Fliess, he reports that he had put the ‘Project’ manuscripts in a drawer. Moreover, by November 29th in a letter [no. 36] to Fliess he writes that he ‘can no longer understand the state of mind in which I hatched out the “Psychology”; I cannot make out how I came to inflict it on you.’ Some fifty years later, along with the letters to Fliess, the ‘Project’ re-emerged, and it was clear that this mainly neurological manuscript had within it the psychological theories of psycho-analysis, although mostly to be found in seed form. In the ‘Project’, specifically at the end of section fifteen under the heading of ‘Primary and Secondary Process in ?’, Freud felt able to define the demarcation made between two distinct processes of the neurone system ?. He writes, that: ‘Wishful cathexis to the point of hallucination [and] complete generation of unpleasure which involves a complete expenditure of defence are described by us as psychical primary process; by contrast, those processes which are only made possible by a good cathexis of the ego, and which represent a moderation of the foregoing, are described as psychical secondary process. It will be seen that the necessary precondition of the latter is a correct employment of the indications of reality, which is only possible when there is inhibition by the ego.’ In other words, then, in the first appearance of the formulation of primary process at least, the discharge of psychic energy (Q and Q?) transferred into wish-fulfilment or affect to the point of hallucination, as seen in dreams, and met by the generation of an unpleasure which appears to exceed the limits of primary defence, as seen in the first encounter with reality by the nascent mind, are described as uninhibited and are called primary process. Such processes, then, which adhere to the principle of psychic inertia (see also Fechner, 1873), and are met by an equal or greater investment of energy contained within the indications of reality and ego, counter or inhibit the wishful discharge (or affect) of those quantities of energy are described as inhibited and are called secondary process. Clearly, then, there are a number of things that we can highlight about this first explanation of primary and secondary processes. Firstly, there is the matter of the strong neurological emphasis present in the writing. The general editor of the STANDARD EDITION, James Strachey, had said in his Editor’s Introduction, on the matter of the project’s neurological emphasis that:

‘… in spite of being ostensibly a neurological document [the ‘Project’] contains within itself the nucleus of a great part of Freud’s later psychological theories. In this respect its discovery was not only of historical interest; it threw light for the first time on some of the more obscure of Freud’s fundamental hypotheses. The help given by the ‘Project’ towards an understanding of the theoretical seventh chapter of ‘The Interpretation of Dreams’ is discussed in some detail in the Editor’s Introduction to that work (Standard Ed., 4, xv ff.) But in fact the ‘Project’, or rather its invisible ghost, haunts the whole series of Freud’s theoretical writings to the very end.’

Even though, the paper had a neurological emphasis on defence, and a tenor apparently contrary to the later psychologically focused emphasis in the psycho-analytic writings proper, the actuality of an evident connection, particularly, in reference to the themes of psychical primary (as uninhibited) and secondary processes (as inhibited), would seem to indicate both a starting point and a telos for those concepts to develop in the mind of Freud. By contrast, to the first ever example given by Freud one might also seek a formulation given by those outside of psycho-analysis, or, those who specialise within the language of psycho-analysis. Firstly, then, in order to better conceptualise the concept of primary process from an interdisciplinary view one can refer to the ethno-biologist Gregory Bateson (1972), when he writes: ‘Classical Freudian theory assumed that dreams were a secondary product, created by “dream work”. Material unacceptable to conscious thought was supposedly translated into the metaphoric idiom of primary process to avoid waking the dreamer.’ Bateson would appear, at first glance at least, to have a strong concept of the analytic formulation of primary process. However, as he continues his train of thought, he overlays psycho-analytic principles, engineered as they were by the observation of conscious human beings, onto the biological imperatives of other members of the mammalian genus, thus: ‘As we have seen, however, many other sorts of information are inaccessible to conscious inspection, including most of the premises of mammalian interaction. It would seem to me sensible to think of these items as existing primarily in the idiom of primary process, only with difficulty to be translated into “rational” terms. In other words, I believe that much of early Freudian theory was upside down.’ Bateson continues by saying: ‘Primary process is characterised (e.g., by Fenichel) as lacking negatives, lacking tense, lacking in any identification of linguistic mood (i.e., no identification of indicative, subjuctive, optative, etc.) and metaphoric. These characterisations are based upon the experience of psychoanalysts, who must interpret dreams and the patterns of free association.’ Bateson’s logic for the application of primary process onto a biological frame, whilst also simultaneously speaking of the analytic clinical technique, appears to be centred on his concern that in Freud’s time, ‘many thinkers regarded conscious reason as normal’, whilst the unconscious remained ‘mysterious, needing proof, and needing explanation.’ He continues, ‘Today we think of consciousness as mysterious, and of the computational methods of the unconscious, e.g., primary process, as continually active, necessary, and all-embracing.’ These are in fact well-constructed and observed thoughts, although some reserve would appear appropriate in whether one should dilute the classical notion of primary process conceived of by Freud as belonging to the human order alongside a liberal contemporary notion of those ‘economics of the system’ as observed in the study of other organisms viewed by biology or computational AI systems. Secondly, then, in order to better conceptualise the concept of primary process from within the ranks of Freudian psychoanalytic thought, one can refer to Laplanche and Pontalis’ (THE LANGUAGE OF PSYCHOANALYSIS, 1973). In this profoundly conscientious work, one may find a greater illumination upon Freud’s concept of, as they note, that which ‘always remained an unchanging co-ordinate of his thought.’ To Laplanche and Pontalis, then, primary process and secondary process should be understood as the two modes specified by Freud, and contemporaneous to the discovery of other unconscious processes, by which the psychical apparatus functions. They continue to define these two processes in a lengthy but necessary passage, thus: ‘… from the topographical point of view, in that the primary process is characteristic of the unconscious system, while the secondary process typifies the pre-conscious – conscious system’ Here, then, the overarching view provided by the topographical view, that is, where topography is as a schematic method for representing the architectonics and terrain of a set of physical or metaphysical systems, the primary process and secondary process are demarked as radically different, if not inimical to each other, in terms of the systems that they serve in isolation. In other words, the primary may be conceptualised as an unstable ‘core system’, the secondary may be conceptualised as the stable ‘sub-processes’ resulting from the output of that given core system, so to speak. However, Freud’s mature metapsychological understanding of and for psyche is said to also exist in other qualitatively different orders. Laplanche and Pontalis add that: ‘from the economic-dynamic point of view: in the case of the primary process, psychical energy flows freely, passing unhindered, by means of the mechanisms of condensation and displacement, from one idea to another and tending to completely recathect the ideas attached to those satisfying experiences which are at the root of unconscious wishes (primitive hallucination).’ That is to say, then, that the overarching view of primary process provided by the economic-dynamic view can be seen as one where the economy of energy and transference of energy are schematised into a precipitation system comprising of displacement and condensation. In the case of displacement, economically speaking, an idea or image comes to be energetically invested (cathected) with a ‘quantity’ of energy equal to the complete ‘quantity’ of discharge (decathected) from, in accordance with what we shall see later as the ‘principle of neuronal inertia’, another idea or image which is related by a chain of associations or associative pathways. This system can be notionally considered as ‘perfectly’ efficient, in the sense that, it does not possess any component which might act as some sort of friction or a brake that might lessen the flow of the quantities of energy attached to the ideas or images. Therefore, the energy attached to these ideas or images are said to be free or unbound in their ability to attach and detach, but, importantly, only as a complete discharge or investment of the original energetic quantity. In the case of condensation, then, economically speaking, the idea or image can be said to have been invested with the sum of the quantities of energy (cathected) which have concentrated or constellated around that given idea or image, which, are associated by the chains and pathways by virtue of a displacement at the point of intersection. Together, therefore, displacement and condensation, as we will see later, can be conceptualised as sub-processes of primary process: ‘… in the case of the secondary process, the energy is bound at first and then it flows in a controlled manner: ideas are cathected in a more stable fashion while satisfaction is postponed, so allowing for mental experiments which test out the various possible paths leading to satisfaction.’ That is to say, the overarching view of secondary process provided by the economic-dynamic view can be seen as one in which the quantities of energy attached to the idea or image do not lead consciousness astray – rather, the waking thought, attention, judgement, reasoning, or otherwise controlled action of psyche is bound by an intermediary agency, which, again, as we shall see later, exercises a regulatory function upon the intensity of energy freighted by the idea or image. Secondary process, then, in the mature theory, is made possible by the establishment of the ego, which, has successfully mediated upon and inhibited the primary process. However, it is worthy of note that, this does not mean that the regulatory function of the ego is always successful.

Developmental contributions

Models of stage development are not necessarily perfect chronological representations, instead they really ought to be seen as subjective maps for us to conceptualise the development of infants. The term stage is used within the context of this language to describe observations without necessarily possessing scientific or explanatory value. Broadly speaking, developmental psychology concerns itself with the study of changes in behaviour and an analysis of their causes. These changes typically take place with age, and as such are widely known as Child Psychology. However, there have been suggestions that psychologists should concern themselves with ‘Life-span’ developmental psychology. As we may recall, there are perhaps three main approaches to the study of developmental psychology: Observational (Tiedemann, Darwin, Piaget) Psychometric (Galton, Pearson, Catell, Binet) and Experimental (Piaget, Vygotsky, Bruner). That said, Freud’s THREE ESSAYS ON THE THEORY OF SEXUALITY (1905) is still regarded as foundational developmental reading. And it was here that the central idea emerges that organises Freud’s account for a psychodynamic developmental stage theory; there is a determined development of successive erotogenic phases, whereby at each phase one particular erotogenic zone dominates the libidinal life of the child. Here, then, pathologies can thus be accounted for in terms of a Fixation at one particular developmental phase, or a Regression to such a phase. One can remember the order of the psychosexual stages by using a mnemonic: old (oral) age (anal) pensioners (phallic) love (latent) greens (genital). As we shall see, these stages refer directly to erotogenic zones of the body.

Oral Stage (0-1 year)

The first stage of personality development is centred on the baby's mouth. It gets much satisfaction from putting all sorts of things in its mouth to satisfy libido, and thus its id demands. Which at this stage in life are oral, or mouth orientated, such as sucking, biting, and breast-feeding. Freud said oral stimulation could lead to an oral fixation in later life. We see oral personalities all around us such as smokers, nail-biters, finger-chewers, and thumb suckers. Oral personalities engage in such oral behaviours particularly when under stress.

Anal Stage (1-3 years)

The libido now becomes focused on the anus and the child derives great pleasure from defecating. The child is now fully aware that they are a person in their own right and that their wishes can bring them into conflict with the demands of the outside world (i.e. their ego has developed). Freud believed that this type of conflict tends to come to a head in potty training, in which adults impose restrictions on when and where the child can defecate. The nature of this first conflict with authority can determine the child's future relationship with all forms of authority. Early or harsh potty training can lead to the child becoming an anal-retentive personality who hates mess, is obsessively tidy, punctual and respectful of authority. They can be stubborn and tight-fisted with their cash and possessions. This is all related to pleasure got from holding on to their faeces when toddlers, and their mum's then insisting that they get rid of it by placing them on the potty until they perform! Not as daft as it sounds. The anal expulsive, on the other hand, underwent a liberal toilet-training regime during the anal stage. In adulthood the anal expulsive is the person who wants to share things with you. They like giving things away. In essence they can be viewed as 'sharing their shit!’ An anal-expulsive personality can also be viewed as messy, disorganised and anti-authoritarian.

Phallic Stage (3 to 5 or 6 years)

Sensitivity now becomes concentrated in the genitals and masturbation (in both sexes) becomes a new source of pleasure. The child becomes aware of anatomical sex differences (penis and the ‘lack’), which sets in motion the conflict between erotic attraction, resentment, rivalry, jealousy and fear which Freud called the Oedipus complex. This universal complex is resolved through the process of identification which involves the child adopting the characteristics of the same sex parent. The most important aspect of the phallic stage is the Oedipus complex. This is one of Freud's most controversial ideas and one that many people reject outright. The name of the Oedipus complex derives from Greek myth of Oedipus the King; a tale of an intelligent young man whose infamy is based upon his unwitting and tragic murder of his father and marriage and sexual relations with to his mother. Upon discovering this ultimate taboo, rather than merely kill himself, Oedipus resolves to suffer and wander the earth a beggar, blinded by his own hand. In the young boy, the Oedipus complex, or more correctly conflict, arises because the boy develops sexual (pleasurable) desires for his mother. He wants to possess his mother exclusively and get rid of his father to enable him to do so. Irrationally, the boy thinks that if his father were to find out about all this, his father would take away what he loves the most. In the phallic stage what the boy loves most is his penis. Hence the boy develops castration anxiety. A problem the little boy then sets out to resolve by imitating, copying and joining in masculine dad-type behaviours. This is called identification, and is how the three-to-five year old boy resolves his Oedipus complex. Identification means internally adopting the values, attitudes and behaviours of the familial type (see imago). The consequence of this is that the boy takes on the male gender role, and adopts an ego ideal and values that become the superego. Simply put, for girls the desire is directed towards the father when she realises that she does not have a penis. This leads to the development of ‘penis envy’ and the wish to be like her father. The girl resolves this by repressing her desire for her father and substituting the wish for a penis with the wish for a symbolic phallic substitute. The girl blames her mother for her 'castrated state' and this creates great tension. The girl then represses her feelings (to remove the tension) and identifies with the mother to take on the female gender role.

Latency (5 or 6 to puberty)

No further psychosexual development takes place during this stage (latent means hidden). The libido is dormant. Freud thought that most sexual impulses are repressed during the latent stage and sexual energy can be sublimated (re: defence mechanism) towards school work, hobbies and friendships. Much of the child's energies arc channelled into developing new skills and acquiring new knowledge and play becomes largely confined to other children of the same gender.

Genital (puberty to adult)

Is the last stage of Freud's psychosexual theory of personality development and begins in puberty. It is a time of adolescent sexual experimentation, the successful resolution of which is settling down in a loving one-to-one relationship with another in our 20's or so. Sexual instinct is directed to heterosexual pleasure, rather than self-pleasure during the phallic stage. For Freud, the proper outlet of the sexual instinct in adults was through heterosexual intercourse. Fixation and conflict may prevent this with the consequence that sexual perversions may develop. For example, fixation at the oral stage may result in a person gaining sexual pleasure primarily from kissing and oral sex, rather than sexual intercourse. Freud espoused a belief that the life-drive [libido] developed in individuals by a process of constant change called sublimation. He argued that humans are born “polymorphously perverse” suggesting that any number of objects could be a source of pleasure. He further argued that as humans develop they become fixated on different and specific objects through their stages of development—first in the oral stage (exemplified by an infant's pleasure in nursing), then in the anal stage (exemplified by a toddler's pleasure in emptying his or her bowels), then in the phallic stage. Freud argued that children then passed through a stage in which they fixated on the mother as a sexual object; known as the Oedipus Complex, but that the child eventually overcame and repressed this desire because of its taboo nature. The repressive or dormant latency stage of psychosexual development preceded the sexually mature genital stage of psychosexual development. Freud hoped to prove that his model was universally valid, and thus turned to classical mythology and contemporary ethnography for comparative material. Freud named his new theory the Oedipus complex after the famous Greek tragedy (see also Homer, Hesiod, Pindar, Aeschylus, Euripides and Sophocles). Freud’s self-analysis led him to write: “I found in myself a constant love for my mother, and jealousy of my father. I now consider this to be a universal event in childhood.” Freud sought to anchor this pattern of development to the dynamics of the mind. Each stage is a progression into adult sexual maturity, characterized by a strong ego and the ability to delay gratification (THREE ESSAYS ON THE THEORY OF SEXUALITY, 1905). It can be said that he used the Oedipal conflict to point out how much he believed that people desire and fantasise upon the incest taboo, and must, therefore, repress this unwelcome desire. The Oedipus conflict was described as a state of psychosexual development and awareness. Freud, under the influence of Carl Jung, also turned to anthropological studies, and went on to argue that totemism reflected an archaic ritualised enactment of a tribal conflict (TOTEM AND TABOO, 1912). Freud originally posited childhood sexual abuse as a general explanation for the origin of neuroses, but he abandoned the ‘seduction theory’ as insufficiently explanatory, noting that he had found many cases in which apparent memories of childhood sexual abuse were based more on fantasy and imagination than on real events. It was during the late 1920s that Freud, who never abandoned his belief in the sexualised aetiology of neuroses, began to emphasize the role of the aggressive fantasy life built around the economical dynamics between the id (the ‘it’) and superego (the authorising function) as the primary source of beliefs, waking affects and neurotic symptoms.

Freud’s method of interpretation has since been argued to be flawed as ‘phallocentric’ by many critical and/or feminist thinkers alike. For Freud’s acolytes the unconscious always desires the phallus (penis) as the primary signifier. Feminity is barred access to a patriarchal signifier. Here, the masculine is positioned as fearing the impotence of a symbolic castration at the hands of a persecutory symbolic father; that is, losing the phallus becomes imaginatively allied to losing masculinity or authority to the more potent image of the imago. Moreover, to this view the female appears always to desire to have a phallus (as an authorising function) in their unconscious fantasy life. Thus, for Freud, the boy resents yet identifies with the father through his fear of castration. Desire, it would seem, is defined in the negative term of lack - always desire the being that you do not have, or we demand what we do not have, and, it is very unlikely that you will fulfil these desires or demands. Thus, psychoanalysis as a technique, endeavours to elucidate on an inner object world of the analysand so that they might better cope with both unrealistic needs, desires, and the irrational demands placed upon us by an authorising society leads to the alienation of that individual. These ideas find particular strength and purchase through the work of the highly influential and radical post-Freudian, Jacques Lacan (b. 1901 – d. 1981). Lacan’s infamous role in the critical call for structuralist and post-structuralist thought to Return to Freud and his role in the Paris riots of May 1968 have been well documented, the clinical theory also endeavoured to show the implausibility of the psychosexual developmental model, and the particular stress on the misreading of Freud to those psycho-analytic schools teaching ego-psychology. Lacan argued that since any serious consideration of what Freud called ‘deferred action’ (Eng. afterwardsness) - and the recurrences of experience known as the return by which events give over a significance to presenting events - would show that the phases in question would take on their values not just synchronically but at later times in the supposed development of a child. Nevertheless, at the most general level, Lacanian psycho-analytic thought retains a concern with structure; it is less concerned with the erotogenic development of the child [contra Freud] than with representational and topological relations held to bind the subject and the object of desire.

It was here, at the level of the sexualised nature of the energetic drive, that most if not all deviations led to the proliferation of the post-Freudian schools of psychoanalytic thought. Most notable among these, perhaps, were Carl Jung (b. 26th July 1875 – d. 6th June 1961) and Melanie Klein (b. 30th March 1882 – 22nd September 1960). Carl Jung’s school of Analytical Psychology de-emphasised the primacy of sexualised energetic drive, demarcated between a personal and a collective unconscious, and proposed the important psychological concepts of Archetype and Imago. Melanie Klein’s Kleinian school de-emphasised the role of the cohesive drive-toward-life (Ger. Lebenstrieben) in favour of the aggressive influence of the destructive drive-toward-death (Todestrieb) found in Freud (BEYOND THE PLEASURE PRINCIPLE, 1920). She also demarcated between conscious fantasy and unconscious phantasy, co-founded the school of thought known as object-relations, and replaced the classical notion of psychosexual developmental stages with her own reductionalist approach to a spectrum of “positions” (Paranoid-schizoid?Depressive functioning).

Psychodynamics

A great deal of the infant’s early learning is dedicated to the area known as social development. Two key aspects within the area of social development are ‘sociability’ and ‘attachment’. Sociability is the tendency to interact in a friendly and positive way with many others. Attachment is a strong and long-lasting emotional bond between two persons characterised by mutual affection and a desire for closeness. One can say that the first monotropic attachments formed by infants are hugely important; and, that these earliest attachments can be considered the starting point for their lifelong social and emotional involvements with others. Put simply, the quality of the earliest attachment[s] can be seen as prototypical for the quality of attachment one-self becomes capable of directing toward the other as one matures (after Ainsworth 1969; 1970; 1978; Bowlby 1944; 1952; 1958; 1969; 1973; 1980; Harlow 1959; Winnicott 1953; 1958).

Ethology & Ethics – Konrad Lorenz & Harry Harlow

Ethologists study animals in their environment in order to gain a better understanding of animal behaviours. One such ethologist, Konrad Lorenz (b. 1903 – d. 1989), rediscovered findings that suggested that the young of some species of birds - in this case greylag geese - appeared to follow the first object they saw after hatching, and continued to follow this same object thereafter. This type of ‘bonding’ was first reported by a nineteenth century biologist called Douglas Spalding, and later described by Lorenz’s mentor Oskar Heinroth as ‘filial imprinting’. That said, working with human subjects is apparently more ethically charged than working with animals, and so in 1959, whilst working with laboratory bred rhesus monkeys, Harry F. Harlow and his team at University of Wisconsin came up with some rather surprising results to their experimentation with infant and parent monkeys. These experiments were to raise significant ethical questions, and make the name Harlow both famous and infamous in equal measure. In Harlow’s initial experiments, infant monkeys were separated from their mothers at six to twelve hours after birth and were raised instead with substitute or surrogate mothers made either of heavy wire mesh or of wood covered with cloth. Both mothers were the same size, but the wire mother had no soft surfaces while the other mother was cuddly – covered with foam rubber and soft terry cloth. Both mothers were also warmed by an electric light placed inside them. In one experiment, both types of surrogates were present in the cage, but only one was equipped with a nipple from which the infant could nurse. Some infants received nourishment from the wire mother, and others were fed from the cloth mother. Even when the wire mother was the source of nourishment (and a source of warmth provided by the electric light), the infant monkey spent a greater amount of time clinging to the cloth surrogate. These results led researchers to believe the need for closeness and affection goes deeper than a need for warmth and food. The monkeys raised by the dummy mothers also appeared to engage in strange behavioural patterns later in their adult life. Some sat clutching themselves, rocking constantly back and forth; a stereotypical behaviour pattern for excessive and misdirected aggression. Normalised sexual behaviours were replaced my misdirected and atypical patterns; that is, isolated females from amongst the experimentation group ignored approaching males from outside the group, while isolated males from the group made inaccurate attempts to copulate with females from outside the group. As parents these isolated female monkeys, the motherless mothers, as Harlow called them, were either negligent or abusive. Negligent mothers did not nurse, comfort, or protect their young, nor did they harm them. The abusive mothers violently bit or otherwise injured their babies, to the point that many of them died. Deprivations of emotional bonds created a crucial cleave in the ability to integrate a secure base for their attachment with their own offspring (see Eysenck, M. W., (2000), Psychology; A Student’s Handbook, and Principles of General Psychology, (1980). Harlow's research suggests the fundamental importance of child/parent and parent/child bonding. Not only does the child look to his/her care-giver for basic needs such as food, safety, and warmth (so-named ‘cupboard love’), but s/he also needs to feel love, acceptance, and affection from the caregiver in equal measure. Harlow’s findings suggest a link between long-term psycho-physical effects of delinquency or inadequate attentiveness and failed emotional needs in the very young which impacts upon the later lives of the adult.

The Well of Despair

Nevertheless, all was not well in the private and social life of Harlow himself. Although his investiga-tions into the ‘nature of love’ and the ‘role of attachment’ were both interesting and productive, the same cannot be said about his post-1960 investigations into the ‘destruction of attachment behaviours’ and ‘the nature of human depression’. This later work with rhesus monkeys, the so-called ‘Well of Despair’ – basically, a blacked out cage intended for ‘total social isolation’ – and the ‘Rape rack’ experiments, marks not only a movement into a manifestly unethical practice, but seemingly heralds and coincides with his own descent into depression and alcoholism - a sad end to an otherwise insightful experimental career as a comparative ethologist. Tragically, Harlow could not be made to see by his students that what he was doing to these animals was cruel and unnecessary. In his own dispassionate and weak defence, he wrote: “No monkey has died during isolation. When initially removed from total social isolation, however, they usually go into a state of emotional shock, characterized by ... autistic self-clutching and rocking. One of six monkeys isolated for 3 months refused to eat after release and died 5 days later. The autopsy report attributed death to emotional anorexia. ... The effects of 6 months of total social isolation were so devastating and debilitating that we had assumed initially that 12 months of isolation would not produce any additional decrement. This assumption proved to be false; 12 months of isolation almost obliterated the animals socially ...”

Attachment, Separation & Loss

John Bowlby was born in 1907. He started his intellectual journey at Cambridge, where he read medicine upon the advice of his surgeon father. In his third year of study, John Bowlby became drawn to what would later be known as developmental psychology, and he temporarily gave up plans for a medical career. After graduation he pursued his new-found interest through volunteering at two progressive schools; the second of these a small analytically-oriented residential institution that served about 24 maladjusted children aged 4-18 years. Bowlby was quite modest about his actual work at the school: “I don't think I would like to describe what I did - I did my best.” Two children there had an enormous impact on him. One was a very isolated, remote and affectionless teenager with no experience of a stable mother figure. This child had been expelled from his previous school for stealing. The second child was an anxious boy of 7 or 8 who trailed Bowlby around, and was known as his shadow. An additional major influence on Bowlby's development was John Alford, one of the other volunteer staff at the school. It was with him that Bowlby spent many hours discussing the affect of early experience, or lack of it, upon character development. By the time Bowlby’s volunteer service ended, John Alford had successfully persuaded him to resume his medical studies in order to pursue training in child psychiatry and psychotherapy so that he might further pursue his ideas about family influences upon children's development. Bowlby had accepted Alford's advice reluctantly because he did not look forward to the medical training which was required as the passport to psychiatry. A saving grace was his immediate acceptance into the British Psychoanalytic Society as a student-candidate. His analyst there was Joan Rivière. He was also supervised by Melanie Klein – the same path as Donald Winnicott before him. Interestingly, training in psychiatry and psychoanalysis provided Bowlby with a reasonably tolerant environment in which to develop his ideas. Much more influential than the analysts and psychiatrists whom had been his teachers were two social workers whom he encountered during his stint as a fellow at the London Child Guidance Clinic upon completion of his training: Christoph Heinecke and James Robertson. These two people shared his ideas about the importance for healthy emotional development of a child's early family experience. Throughout this period, Bowlby felt very strongly that psychoanalytic thought was putting far too much emphasis on the child’s phantasy world and far too little on actual events. He expressed this view in an interesting paper ‘The Influence of Early Environment in the development of neurosis and neurotic character’, (1940), Int. Journal of Psychoanal., XXI, 1-25, which already contains many of the ideas which were later to become central to attachment theory. In emphasising the influence of early family environment on the development of neurosis, he claimed that “psychoanalysts like the nurseryman should study intensively, rigorously, and at first hand, the nature of the organism, the properties of the soil and the interaction of the two”. Bowlby dwelt on the adverse affects of early separation, advising mothers to visit their young children in the wards.

Following his own injunction for more rigorous studies, Bowlby used case-notes from his work at the child guidance clinic to prepare the classic paper on Forty-Four Juvenile Thieves, their characters and home lives (published in 1944). Here, a significant minority of the children turned out to have affectionless characters, a phenomenon Bowlby linked to their histories of maternal deprivation and separation. Upon returning from army service in 1945, Bowlby became head of the Children's Department at the Tavistock Clinic. In order to highlight the importance of the parent-child relationship, he promptly renamed it The Department for Children and Parents. Unlike most psychoanalysts of his time - and of ours- Bowlby was deeply interested in finding out the actual patterns of family interaction involved in both healthy and pathological development. Directing this department entailed running a clinic, undertaking training and doing research. To Bowlby's disappointment, much of the clinical work on the department was done by people with a Kleinian orientation, who regarded his emphasis on actual family interaction patterns as largely irrelevant. Because of this approach rift, Bowlby had to found his own research unit because he could not use the department's clinical cases for the research he was after. In 1948, after obtaining his first research funds, Bowlby hired James Robertson to do observations of young children who were hospitalised, institutionalised or otherwise separated from their parents. It is well-known that Bowlby focused the efforts of his research team on a well-circumscript area: mother-child separation, because separation is a clear-cut event that either happens or does not. After two years of collecting data in hospitals, Robertson could not continue as an ‘uninvolved’ scientist. He felt compelled to do something for the children he had been observing, and he made the deeply moving film entitled ‘A two-year-old goes to hospital’ (Robertson and Bowlby 1952, Robertson 1953). In collaboration with Bowlby, the filming was carefully planned to ensure that no one could later be able to claim that it was biased. Bowlby and Robertson decided to use time-sampling, documented by the clock which was always in the picture, to prove that the film segments were not specially selected. Not only did this film play a crucial role in the development of ‘Attachment Theory’ but it also helped improve the fate of children in hospitals in Britain and many other parts of the world. In light of the research on separation then going on at the Tavistock Centre, he received and accepted a request made by the World Health Organisation (WHO) to write a report on the fate of homeless children in post-war Europe.

The World Health Organisation subsequently published it in 1951 under the title of Maternal Care and Mental Health. The task of writing the WHO report made Bowlby realise that the material he was gathering cried out for a theory that could explain the profound effects of separation and deprivation experiences on young children. At this point Bowlby was fortunate to meet Robert Hinde, under whose generous and stern guidance he set about trying to master the principles of ethology in the hope that they might help him gain a deeper understanding of the nature of the child's tie to the mother. In 1954, Robert Hinde began to attend regular seminars at the Tavistock Centre and later drew Bowlby's attention to Harlow's work with rhesus monkeys. However, the influence was not merely a one-way transaction. The contact with Bowlby was instrumental in Hinde’s decisions to mother-infant interaction and separation in rhesus monkeys that were reared in social groups. Bowlby's first formal statement of ‘Attachment Theory’, drawing heavily on ethological concepts, was presented in London in three now classic papers read to the British Psychoanalytic Society. The first, THE NATURE OF THE CHILD'S TIE TO HIS MOTHER was presented in 1957 where he reviews the current psychoanalytic explanations for the child's libidinal tie to the mother (in short, the theories of secondary drive, primary object sucking, primary object clinging, and primary return to womb craving). This paper raised quite a storm at the Psychoanalytic Society. Anna Freud, who missed the meeting but read the paper, wrote: “Dr Bowlby is too valuable a person to get lost to psychoanalysis”. The next paper in the series SEPARATION ANXIETY was presented in 1959. In this paper, Bowlby pointed out that traditional theory fails to explain both the intense attachment to mother figures, and young children’s dramatic responses to separation. Robertson and Bowlby had identified three main phases of and for separation response:

All of which appeared to support Bowlby's crucial point: separation anxiety is experienced when attachment behaviour is activated and cannot be terminated unless reunion is restored. Unlike other analysts, Bowlby advanced the view that excessive separation anxiety is usually caused by adverse family experiences, such as repeated threats of abandonment or rejections by parents, or to parent’s or siblings’ illnesses or death for which the child feels responsible. In the third major theoretical paper, GRIEF AND MOURNING IN INFANCY AND EARLY CHILDHOOD, read to the Psychoanalytic Society in 1959 (published in 1960), Bowlby questioned the then prevailing view that infantile narcissism is an obstacle to the experience of grief upon loss of a love object. He disputed Anna Freud’s contention that infants cannot mourn, because of insufficient ego development, and hence experience nothing more than brief bouts of separation anxiety provided a satisfactory substitute is available. He also questioned Melanie Klein’s claim that loss of the breast at weaning is the greatest loss in infancy. Instead, he advanced the view that grief and mourning appear whenever attachment behaviours are activated but the mother continues to be unavailable.

Attachment in Synopsis

A child has an innate (i.e. inborn) need to attach to one main attachment figure (i.e. monotropy). Although Bowlby did not rule out the possibility of other attachment figures for a child, he did believe that there should be a primary bond which was much more important than any other (usually the mother). Bowlby believes that this attachment is different in kind (qualitatively different) from any subsequent attachments. Bowlby argues that the relationship with the mother is somehow different altogether from other relationships. Essentially, Bowlby suggested that the nature of monotropy (attachment conceptualised as being a vital and close bond with just one attachment figure) meant that a failure to initiate, or a breakdown of, the maternal attachment would lead to serious negative consequences, possibly including affectionless psychopathy. Attachment is an emotional bond to another person. Psychologist John Bowlby was the first attachment theorist, describing attachment as a “…lasting psychological connectedness between human beings" (Bowlby, 1969, p. 194). Bowlby believed that the earliest bonds formed by children with their caregivers have a tremendous impact that continues throughout life. According to Bowlby, attachment also serves to keep the infant close to the mother, thus improving the child’s chances of survival. The central theme of attachment theory is that mothers who are available and responsive to their infant’s needs establish a sense of security. The infant knows that the caregiver is dependable, which creates a secure base for the child to then explore the world. Bowlby’s theory of monotropy led to the formulation of his maternal deprivation hypothesis.

A child should receive the continuous care of this single most important attachment figure for approximately the first two years of life. Bowlby (1951) claimed that mothering is almost useless if delayed until after two and a half to three years and, for most children, if delayed till after 12 months, i.e. there is a critical period. If the attachment figure is broken or disrupted during the critical two year period the child will suffer irreversible long-term consequences of this maternal deprivation. Bowlby used the term maternal deprivation to refer to the separation or loss of the mother as well as failure to develop an attachment. The underlying assumption of Bowlby’s Maternal Deprivation Hypothesis is that continual disruption of the attachment between infant and primary caregiver (i.e. mother) could result in long term cognitive, social, and emotional difficulties for that infant. The implications of this are vast – if this is true, should the primary caregiver leave their child in day care, whilst they continue to work? The long term consequences of maternal deprivation can include the following symptoms:

Affectionless psychopathy is an inability show affection or concern for others. Such of individuals act on impulse with little regard for the consequences of their actions. For example, subjects presenting no trace of guilt after an incident involving anti-social behaviour.

‘44 Juvenile Thieves’: A Case Study (Bowlby 1944)

John Bowlby believed that the relationship between the infant and its mother during the first five years of life was most crucial to socialisation. He believed that disruption of this primary relationship could lead to a higher incidence of juvenile delinquency, emotional difficulties and antisocial behaviour. To support his hypothesis, he studied 44 adolescent juvenile delinquents in a child guidance clinic.

Aim: To investigate the effects of maternal deprivation on people in order to see whether delinquents have suffered deprivation. According to the Maternal Deprivation Hypothesis, breaking the maternal bond with the child during the early stages of its life is likely to have serious effects on its intellectual, social and emotional development.

Procedure: Bowlby interviewed 44 adolescents who were referred to a child protection program in London because of stealing- i.e. they were thieves. Bowlby selected another group of 44 children to act as ‘controls’. N.B: controls: individuals referred to clinic because of emotional problems, but not yet committed any crimes. He interviewed the parents from both groups to state whether their children had experienced separation during the critical period and for how long.

Findings: More than half of the juvenile thieves had been separated from their mothers for longer than six months during their first five years. In the control group only two had had such a separation. He also found several of the young thieves (32%) showed 'affectionless psychopathy' (they were not able to care about or feel affection for others). None of the control group were affectionless ‘psychopaths’. In a later paper, he reported that 60 children who had spent time apart from their mothers in a tuberculosis sanatorium before the age of 4 showed lower achievement in school.

Conclusion: Affectionless psychopaths show little concern for others and are unable to form relationships. Bowlby concluded that the reason for the anti-social behaviour and emotional problems in the first group was due to maternal deprivation. Evaluation: The supporting evidence that Bowlby (1944) provided was in the form of clinical interviews of, and retrospective data on, those who had and had not been separated from their primary caregiver. This meant that Bowlby was asking the participants to look back and recall separations. These memories may not be accurate. Bowlby designed and conducted the experiment himself. This may have lead to experimenter bias as it was Bowlby who was responsible for making the eventual diagnosis of “affectionless psychopathy.”

Categories of Attachment

During the 70s, researcher Mary Ainsworth further expanded upon Bowlby’s groundbreaking work in her now-famous ‘Strange Situation’ study. The study involved observing children between the ages of 12 to 18 months responding to a situation in which they were briefly left alone and then reunited with their mother (Ainsworth, 1978). Based on these observations, Ainsworth famously concluded that there were three major styles of attachment: ‘secure attachment’ (70%), ‘ambivalent-insecure attachment’ (15%) and ‘avoidant-insecure attachment’ (15%). Numerous studies have supported Ainsworth’s conclusions and additional research has revealed that these early attachment styles can help predict behaviours later in life.

Strange Situation Procedure (Ainsworth & Bell 1970)

The security of attachment in one- to two-year-olds was investigated by Ainsworth and Bell (1970) in the 'strange situation' study, in order to determine the nature of attachment behaviours and types of attachment. Ainsworth (1970) developed an experimental procedure in order to observe the variety of attachment forms exhibited between caregivers and infants. The experiment is set up in a small room with one way glass so the behaviour of the infant can be observed. Infants were aged between 12 and 18 months. The sample comprised about 100 middle class American families. The procedure, known as the ‘Strange Situation’, was conducted by observing the behaviour of the caregiver and the infant in a series of seven 3-minute episodes, as follows:

Findings: Ainsworth’s set of observational studies using the ‘Strange Situation’ paradigm (see below) revealed three distinct forms of attachment (‘attachment styles’); one secure attachment style and two types of insecure attachments. Caregivers and infant pairs displayed one of the following three attachment styles.

Conclusions: Ainsworth & Bell suggested that behaviour in the strange situation classification was determined by the behaviour of the primary carer. For example, securely attached infant are associated with sensitive & responsive primary care. Insecure Resistant attached infants are associated with inconsistent primary care. Sometimes the child’s needs and met and sometime they are ignored by the mother. Insecure Avoidant infants are associated with unresponsive primary care. The child comes to believe that communication of needs has no influence on the mother.

Evaluations of the ‘Strange Situation’: The strange situation classification has been found to have good reliability. This means that it achieves consistent results. For example, a study conducted in Germany found 78% of the children were classified in the same way at ages 1 and 6 years (Wartner et al., 1994). The strange situation classification has become the accepted methodology worldwide for measuring attachment (van Ijzendoorn and Kroonenberg, 1988). Mary Ainsworth's conclusion that the strange situation can be used to identify the child's type of attachment has been criticised on the grounds that it identifies only the type of attachment to the mother. The child may have a different type of attachment to the father or grandmother for example (Lamb, 1977). This means that is lacks validity, as it is not measuring a general attachment style, but instead an attachment style specific to the mother. In addition, some research has shown that the same child may show different attachment behaviours on different occasions. Children's attachments may change, perhaps because of changes in the child's circumstances, so a securely attached child may appear insecurely attached if the mother becomes ill or the family circumstances change. The strange situation has also been criticised on ethical grounds. Because the child is put under stress (separation and stranger anxiety), the study has broken the ethical guideline protection of participants. The sample is biased -100 middle class American families. Therefore, it is difficult to generalise the findings outside of America and to working class families. Finally, the observational study has been criticised for having low ecological validity because the child is placed in a strange and artificial environment, due to the procedure of the mother and stranger following a predetermined script:

•Secure attachment: Children who are securely attached do not experience significant distress when separated from caregivers. When frightened, these children will seek comfort from the parent or caregiver. Contact initiated by a parent is readily accepted by securely attached children and they greet the return of a parent with positive behaviour. While these children do not become exceptionally distressed by a parent’s absence, they clearly prefer parents to strangers.

• Ambivalent-insecure attachment: Children who are ambivalently attached tend to be extremely suspicious of strangers. These children display considerable distress when separated from a parent or caregiver, but do not seem reassured or comforted by the return of the parent. In some cases, the child might passively reject the parent by refusing comfort, or may openly display direct aggression toward the parent.

• Avoidant-insecure attachment: Children with avoidant attachment styles tend to avoid parents and caregivers. This avoidance often becomes especially pronounced after a period of absence. These children might not reject attention from a parent, but neither do they seek comfort or contact. Children with an avoidant attachment show no preference between a parent and a complete stranger.

Researchers Main and Solomon (1986) added a fourth attachment style known as ‘disorganized-insecure attachment’.

• Disorganized-insecure attachment: Children with a disorganized-insecure attachment style show a lack of clear attachment behaviour. Their actions and responses to caregivers are often a mix of behaviours, including avoidance or resistance. These children are described as displaying ‘dazed’ behaviour, sometimes seeming either confused or apprehensive in the presence of a caregiver.

Critique of Attachment Theory

Bowlby used the term maternal deprivation to refer to the separation or loss of the mother as well as failure to develop an attachment. Michael Rutter (1981) argued that if a child fails to develop an attachment this is privation, whereas deprivation refers to the loss of or damage to an attachment. In Rutter's view, deprivation occurs when the child's attachment is damaged or broken due to either separation from the attached figure, or loss of the attached figure, for instance through divorce or death. There may be short and long term effects of deprivation. We have considered the short term effects earlier, but Rutter views the reasons for the loss of an attachment as crucial in the explanation of long term effects. Rutter's (1976) evidence from his own research on the long term effects of early separation from mothers reveals the importance of the home environment and previous experiences. His sample comprised 9-12-year-old boys from London and from the Isle of Wight. He looked particularly at anti-social behaviour. His results indicated that:

• There was more anti-social behaviour in boys from families where the parents' marriage was rated as 'very poor' or where parent-child relationships were cold or neglectful;

• There was no difference in anti-social behaviour between boys who had separated from one parent and those who had separated from both parents;

• When a parent died, a child was only slightly more likely to become delinquent than a child from an 'intact' home;

• Boys who were separated because of illness or housing problems did not become maladjusted.

Rutter concluded that there was no correlation between separation experiences and delinquency. He argued that delinquency is not caused by disruption of the bond (as Bowlby claimed) because when disruption was final with the death of a parent, there was only a slight increase in delinquency. Rutter did find that there was a correlation between family discord and delinquency, suggesting that family discord (such as arguing, lack of affection, stress) created a distortion of family relationships. Rutter argued that this was not particularly related to early childhood, as Bowlby claimed. The distorted relationships may be linked to insecure attachments, perhaps even preventing the formation of attachments (privation). Rutter noted that the long term effects of deprivation showed:

• An increase in anti-social behaviour where the separation had been related to family discord or a history of disturbance in the life of the young person;

• Children with secure attachments and those who had experienced successful separations previously seemed to be able to withstand the effects of deprivation more than a child whose attachments were insecure;

• Children differ in their ability to cope with the effects of deprivation; boys appear to be more vulnerable to these effects than girls, as do children between seven months and three years of age.

Are the effects of maternal deprivation as dire as Bowlby suggested? For Rutter, (1972) in his book ‘Maternal Deprivation Re-assessed’, he suggested that Bowlby may have oversimplified the concept of maternal deprivation. For Rutter it was clear that Bowlby had used the term 'maternal deprivation' to refer to separation from an attached figure, loss of an attached figure and failure to develop an attachment to any figure. But each has different effects argued Rutter. In particular Rutter distinguished between privation and deprivation. Rutter (1981) went on to argue that if a child fails to develop an attachment this is privation, whereas deprivation refers to the loss of or damage to an attachment. Deprivation might be defined as losing something in which a person once had, whereas privation might be defined as never having something in the first place. Privation occurs when there is a failure to form an attachment to any individual, perhaps because the child has a series of different carers (which was the case for many of Bowlby's juvenile thieves) or family discord prevents the development of attachment to any figure (as Rutter proposed). Privated children do not show distress when separated from a familiar figure, which indicates a lack of attachment. From his survey of research on privation, Rutter proposed that it is likely to lead initially to clinging, dependent behaviour, attention-seeking and indiscriminate friendliness, then as the child matures, an inability to keep rules, form lasting relationships, or feel guilt. He also found evidence of anti-social behaviour, affectionless psychopathy, and disorders of language, intellectual development and physical growth. Rutter argues that these problems are not due solely to the lack of attachment to a mother figure, as Bowlby claimed, but to factors such as the lack of intellectual stimulation and social experiences which attachments normally provide. In addition, such problems can be overcome later in the child's development, with the right kind of care. Many of the 44 thieves in Bowlby’s study had been moved around a lot during childhood, and had probably never formed an attachment. This suggested that they were suffering from privation, rather than deprivation, which Rutter suggested was far more deleterious to the children. This finding led Hodges and Tizard (1989) toward a very important study on the long term effects of privation.

‘Privation’ - Hodges and Tizard (1989)

Aim: To investigate the effect of institutional upbringing on later attachments; to investigate the effects of privation on later social and emotional development; and, to investigate if the effects of privation can be reversed.

Procedure: Jill Hodges and Barbara Tizard (1989) followed the development of 65 children who had been in residential nurseries from only a few months old. This is known as a longitudinal study. The study was also a field experiment. The independent variable (what happened to the children at age 4) occurred naturally. The care provided was of good quality, but carers were discouraged from forming attachments with the children (i.e. privation occurred). By age 4, 24 children were adopted, 15 returned to their natural home (restored), and the rest stayed in institutions. They were also compared with a control group, who had spent all their lives in their own families. The control group was closely matched to the children in the experimental group. For example, in terms of sibling number, home location (London), parental occupation, position in family, age, sex etc. The children were assessed for social and emotional competence at four, eight and sixteen years old. The assessment comprised interviewing the children and their parents and teachers and a set of questionnaires.

Findings: At four years of age none of the institutionalised children had formed attachments, but by eight years of age those who were adopted had formed good attachments. Also their social and intellectual development was better than that of children returned to their own families. Those returned to their natural families (restored) showed more behavioural problems and the attachments were weaker. Nevertheless all those children who had spent their early years in institutions were more attention-seeking from adults and showed some difficulties in their social relationships, particularly with their peers. Some of these children were interviewed again at 16 years of age, as were their parents and care-workers. They were compared with a new control group as the original control children no longer matched the children in the adopted and restored groups. Hodges and Tizard found that the adopted children still had good attachments which compared favourably with the control children. Fewer restored children were reported as having good attachments but the children who had been brought up in institutional care had experienced most instability and showed some difficulties in their later attachments.

Conclusion: Hodges and Tizard concluded from this evidence that Bowlby was correct to emphasize the importance of the early years, but the effects of delay in the formation of attachments do not necessarily persist into adulthood and lead to affectionless psychopathy, as Bowlby predicted. Indeed, loving relationships and high quality care are necessary to reverse privation effects.

Evaluation: Hodges and Tizard used interviews and questionnaires, both of which can produce answers that are affected by social desirability - the wish to appear in a good light. The responses of those interviewed may have been inaccurate, and this would affect the results. Another difficulty in this research is that six of the original 51 families of eight-year-olds refused to take part in this later research. It could be that families experiencing more difficulties were more likely to refuse, and this may also apply to the comparison group, because the families who agreed to take part may have been those with fairly good relationships with their 16-year-olds. Thus, the results of the research may be biased due to the sample. Institutionalised children don’t just suffer emotional privation but also poor physical care such as bad diet and also lack of stimulation. As a result it is difficult to separate out the effects of privation and of physical care.

The ethological and analytical origins of attachment theory have been brought by Bowlby into sharp focus. That is to say, attachment theory can now more clearly be seen as a theory of interpersonal relationships in the lineage of object relations theory whilst also incorporating the behavioural findings from ethology. Nonetheless, it may also be said that socialisation and attachment theories shed a new more rigorous perspective on the questions raised originally by the clinical analysis of Melanie Klein and Donald Winnicott. Thus, the importance of Bowlby’s work cannot be overstated and suggests itself as ultimately stemming from a single abstract thought; a thought to describe an all-too common worldly phenomenon of loss; a thought first hypothesised by Freud many years before, only later to be empirically measured by Bowlby; that is, a thought concerning the reflex of anxiety or signal anxiety triggered, one might say, by the fear of the loss of love. Bowlby’s ideas have had a great influence on the way researchers and parents think about attachment and much of the discussion of his theory has focused on his firm belief in monotropic bonding. Although Bowlby does not dispute that young children form multiple attachments, he still contends that the attachment to the mother is unique in that it is the first to appear and remains the strongest attachment of all. However, on both of these counts, mounting evidence seems to suggest otherwise.

Schaffer & Emerson (1964) have noted that specific attachments started at about 8 months and, very shortly thereafter, the infants became attached to other people. By 18 months very few (13%) were attached to only one person; some had five or more attachments. Rutter (1981) points out that several indicators of attachment (such as protest or distress when attached person leaves) has been shown for a variety of attachment figures – fathers, siblings, peers and even inanimate objects. Critics such as Rutter have also accused Bowlby of not distinguishing between deprivation and privation – the complete lack of an attachment bond, rather than its loss. Rutter stresses that the quality of the attachment bond is the most important factor, rather than just deprivation in the critical period. Another criticism of the ‘44 Thieves Study’ is that it concluded that affectionless psychopathy was caused by maternal deprivation. The data correlation shows a modest relationship between these two variables. Indeed, other external variables (e.g. diet, parental income, education etc.) may also have affected the behaviour of the ‘44 thieves’, and not, as concluded, solely the disruption of the attachment bond. Bowlby's notion of ‘Maternal Deprivation’ is however supported Harlow's ethological research with monkeys. Harlow showed that monkeys reared in isolation from their mother suffered emotional and social problems in older age. The monkey's never formed an attachment (privation) and as such grew up to be aggressive and had problems interacting with other monkeys. There are implications arising from Bowlby’s work. As he believed the mother to be the most central care giver and, that this care should be given on a continuous basis, an obvious but somewhat naïve conclusion would be that mothers ought not to go out to work. Needless to say, there have been many attacks on this claim. Mothers are the exclusive carers in only a very small percentage of human societies; more often than not there are often a number of people involved in the care of children, such as relations and friends (Weisner & Gallimore 1977). In fact, Ijzendoorn & Tavecchio (1987) have argued that a stable network of adults can provide adequate care, and that this care may even have advantages over a system where a mother has to meet all of a child’s needs. There is also evidence (Schaffer 1990) that children develop better with a mother who is happy in her work, than a mother who is frustrated by staying at home.

Object Relations

Object relations theory can be described as a contemporary adaptation of psychoanalytic theories which places less emphasis on the drives of aggression and sexuality and pleasure, as motivational forces, and more emphasis on human relationships as the primary motivational force in life. That is, object relations theorists believe that we are relationship seeking rather than pleasure seeking, as Freud had originally suggested. The importance of relationship stressed within the theory translates directly to relationship as the main focus of the psychotherapeutic work, especially so in the relationship between the patient and the therapist. We may recall that Freud originally used the term object to mean anything an infant directs drives toward for satiation or pleasure. As previously noted drives are of two types; libidinal and aggressive. Accordingly, objects became a key component of Freud’s (DAS ICH UND DAS ES, 1923B) structural model of and for the human psyche.Since Freud, however, many theorists such as Melanie Klein, Ronald Fairbairn, Donald Winnicott, Edith Jacobson, Otto Kernberg and Heinz Kohut moved, to varying degrees, toward a relational/structural model of the psyche in which an object is seen as the target of relational needs in human development (see Greenberg & Mitchell’s OBJECT RELATIONS IN PSYCHOANALYTIC THEORY, 1983). Object relations theorists believe that humans have an innate drive to form and maintain relationships, and that this is privileged as the fundamental human need which forms a context against which other drives, such as, libidinal and aggressive drives, gain meaning. Within modern object relations theory, objects can be people (mother, father, others) or things, such as transitional objects with which we form attachments. These objects and the developing child’s relationship with them are incorporated into an understanding of self, and become the building blocks of the self-system. Some have asked; Why not just call it human relations instead object relations? Otto Kernberg has suggested that we could do this without changing the meaning of the theory (BORDERLINE CONDITIONS AND PATHOLOGICAL NARCISSISM.1975). However, it appears important to continue using the term object because we form relationships with things other than people. In childhood, a fact recognised by the doyen of object-relations theory, Donald Winnicott, we form relationships with our stuffed animals, toys and pets. He terms these transitional phenomena/objects (MATURATIONAL PROCESSES AND THE FACILITATING ENVIRONMENT: STUDIES IN THE THEORY OF THE EMOTIONAL DEVELOPMENT, 1965). Of course some people form intense and even self-destructive relationships with food, alcohol, substances, as well as with people, thus, the term object is more inclusive for our understanding of how humans form and preserve a sense of self, as well as relationships with others. Another way of looking at this is that we come into the world with a genetic encoding that sets the stage for who or what it is which we have the unique potential to become (true self organisation). However, it is also our interactions with significant others, such as the so-named “good enough [m]other”, that also shape how our genetic predispositions may be distorted (false self). Early in life, we have little sense of ourselves, or our identity as separate from our primary caregivers. It is, therefore, through our relationships with the significant people around us that we take in parts of others (part objects and whole objects) and slowly build a self-structure, which we eventually call a personality. This blueprint of a self-structure is formed early in life out of our relationships with the “good enough” objects, significant others, and parts of significant others, around us which facilitate our maturational process. Once formed, the blueprint of self can be modified, says Heinz Kohut (THE ANALYSIS OF THE SELF: A SYSTEMATIC APPROACH TO THE PSYCHOANALYTIC TREATMENT OF NARCISSISTIC PERSONALITY DISORDERS, 1971), but our basic tendency is to seek out others who will reaffirm these early self-object relationships. For Kohut, it is as if in early childhood we create a script for a drama and then spent the rest of our lives seeking out others to play the parts. This does not mean the script cannot be changed, however, the more traumatic our early self-object relations, the more rigid and resistant to change we can become. Many object relations theorists see psychological dysfunction as an expression of some arrest to development at some stage, leaving the individual unable to mature further from this position. From this perspective, dysfunctional and symptomatic behaviours are really an immature attempt to resolve early traumas. However, these attempts typically fail since we use immature manipulations to get others, who are similarly engaged in their own manipulations, to meet our unmet needs and desires stemming out of these early psychical traumas. Resolution requires a special relationship with a trained professional. Accordingly, psychotherapy is the process that allows a resolution of the traumatic crisis through a transitional relationship which uses the therapist as if a ‘good enough’ caregiver. Psychopathology, to this way of thinking, is simply therefore an expression of traumatic self-object internalisations borne out from childhood and thenceforward enacted in our everyday relations. Psychotherapy, then, for the psychodynamic object relations theorist, aims to resolve the self-destructive patterns said to emanate from a false conception of self-relations (e.g. narcissism) such that we can mature and realise the unique potentiality of our ‘true self’ in relation ourselves and others.

Behaviourist, Humanist & Cognitive Psychotherapies

The practice of behavioural therapies borrowed principles from physiology, animal psychology (Ethology), Methodological Behaviourism, Logical Behaviourism, Psychoanalytic theory, and Psychodynamic theory (John Bowlby’s Attachment theory) to treat the emotional and behavioural problems of humans. Over the years, behaviour therapy has been enhanced to include emphasis on the cognition (i.e. belief processes) of the person. Rational Emotive Behaviour Therapy (REBT), the first of the modern cognitive behaviour therapies, was developed in 1955 by Albert Ellis (b. 27th September 1913). REBT is an action and results oriented psychotherapy which teaches individuals, within the working alliance of client and therapist, how to identify their own self-defeating thoughts, beliefs and actions and replace [through disputing] them with more effective, life-enhancing ones [through reformulation] (REASON AND EMOTION IN PSYCHOTHERAPY, 1962). Cognitive Therapy (CT) is based on the concept that changing negative thinking patterns and behaviours can have a powerful effect on a person's emotions (see Aaron Beck’s COGNITIVE THERAPY AND THE EMOTIONAL DISORDERS, 1975; or Christine Padesky’s MIND OVER MOOD, 1995). CT helps identify, analyse and change counter-productive thoughts and behaviours, which, in turn, helps to alleviate feelings of depression and anxiety. The combination therapy modality, cognitive-behavioural therapy (CBT), has become a popular type of treatment sanctioned by many leading psychiatric institutions.

The objective of Gestalt Therapy, espoused its creator Fritz Perls (b. 8th July 1893 – d. 14th March 1970), in addition to obviously helping the client overcome distressing symptoms, is to enable the subject to become more fully and creatively alive; to be free from the blocks and unfinished issues which may diminish optimum satisfaction, fulfilment, and growth (EGO, HUNGER AND AGGRESSION, 1942, 1947; THE GESTALT APPROACH AND EYE WITNESS TO THERAPY, 1973). Thus the gestalt approach falls in the category of humanistic psychotherapies. To this was added the insights of academic Gestalt psychology about perception, gestalt formation and the tendency of organisms to complete the incomplete gestalt, to form a “wholeness” for experiences. Additional influences include those from existentialism, particularly that called the “I-Thou” relation (see Martin Buber’s ICH UND DU, 1923) as it applies to therapy, and the notion of personal choice and responsibility. Central to Fritz and Laura Perls’ modifications of psychoanalysis was the concept of dental or oral aggression. Dental aggression is discussed in Fritz Perl’s first book, EGO, HUNGER, AND AGGRESSION (1944). The Perls’ had suggested that when the infant develops teeth, he/she has the capacity to chew, to break apart food, and by analogy experience, to taste, accept, reject, assimilate. This is opposed to Freud’s notion that only introjection takes place in early experience. Thus, the Perls’ made assimilation, as opposed to introjection, a focal theme in their work, and the prime means by which growth occurs in therapy. In contrast to the psychoanalytic stance in which the patient introjects the (presumably more healthy) attitudes/interpretations of the analyst, in Gestalt Therapy the patient must taste his/her experience, and either accept or reject, but not introject or swallow whole. Hence, the emphasis is on avoiding interpretation and encouraging discovery - this is the key point in the divergence of GT from traditional psychoanalysis; that is, growth occurs through gradual assimilation of experience in a natural way, rather than by accepting the interpretations of the analyst; thus, the therapist should not interpret, but lead the patient to discover for him or herself. The Gestalt therapist contrives experiments that lead the patient to greater awareness and fuller experience of his/her possibilities. Experiments can be focussed on undoing identifications, projections or retroflections. They can work to help the client with closure of unfinished gestalts [as if ‘unfinished business’ such as unexpressed emotions towards somebody in the client’s life]. There are many kinds of experiments that might be therapeutic. However, the essence of the work is that it is experiential rather than interpretive, and in this way distinguishes itself from psychoanalytic practice. Perls also derived much from Wilhelm Reich’s (b. 24th March 1897 – d. 3rd November 1957) emphasis on how psychological defences are embodied, and therefore paid a great deal of attention to nonverbal behaviour (DIE FUNKTION DES ORGASMUS : ZUR PSYCHOPATHOLOGIE UND ZUR SOZIOLOGIE DES GESCHLECHTSLEBENS, 1927). This confluence was perhaps consonant with Laura Perls’ background in dance and movement therapy. A core concept in Gestalt therapy is the unifying idea of contact. Contact is where one person meets another person, or meets the outside world. Thus, there can be physical contact, but mostly what is meant by the term is a metaphor for contact. If contact is not interfered with by a disturbance to the contact boundary, the individual can grow, through assimilation of new experiences. In therapy, the client is encouraged to experience his or her own feelings and behaviours in the here and now, and attention is brought to bear on the way contact is interrupted. The way in which he or she interrupts contact with the present environment is considered to be a significant factor in creating and maintaining dysfunctional patterns of behaviour. Some of the contact interruptions occur through projection [finding outside oneself what belongs to oneself], introjection (‘swallowing whole’ instead of assimilating in parts); retroflection (directing impulses towards the self that rightly should be directed to the other, as in anger directed toward self-causing depression or psychosomatic symptoms); confluence (dissolving the self-other boundary and merging with the other). A type of disturbance - introduced by Miriam and Erv Polster - is deflection, referring to a means of avoiding contact by jumping around from one thing to another and never staying in the same place for very long. All of these disturbances have a pathological and a non-pathological aspect. For example, it is appropriate for an infant and mother to become confluent, or two lovers, but inappropriate for client and therapist. When the latter pair becomes confluent, there can be no growth because there is no boundary at which the one can contact the other; the client will not be able to learn anything new because the therapist is simply an extension of the client, so to speak.

The Person-centred or Client-centred therapy developed by Carl Rogers during the 1940s focused on the transmission of warmth, genuineness and acceptance from the humanistic therapist to the individual (CLIENT-CENTRED THERAPY: ITS CURRENT PRACTICE, IMPLICATIONS AND THEORY, 1951; ON BECOMING A PERSON: A THERAPIST'S VIEW OF PSYCHOTHERAPY, 1961). Rogers’ proposal is that a therapist should exhibit unconditional positive regard for their clients – though it might be suggested that a conditional positive regard may be more sustainable and realistic. Other interpersonal therapists have emphasised the importance of the working alliance between therapist and client. The next major shift within psychotherapy was developed not as the result of new ideas, but due to economic issues. Traditionally, psychotherapy was a long progress, often involving years of treatment. As psychotherapy and counselling became more widely available, emphasis was placed on a more brief form of time-limited treatment. This trend was further driven by the arrival of managed care insurance plans and limitations to coverage for mental health issues. Today, virtually all therapeutic modalities offer some sort of brief time-limited therapies designed to help the person deal with specific problems: Malan (INDIVIDUAL PSYCHOTHERAPY AND THE SCIENCE OF PSYCHODYNAMICS, 1976) describes psychoanalytic therapy from four to fifty sessions, Beck & Emery (ANXIETY DISORDERS & PHOBIAS: A COGNITIVE PERSPECTIVE, 1985) session durations of eight to twenty sessions, and Ryle & Kerr (INTRODUCING COGNITIVE ANALYTIC THERAPY: PRINCIPLES & PRACTICE, 2002) describes cognitive-analytic therapy utilising from eight to thirty six sessions.

Let us turn to a context for the postmodern narrative. Here I have chosen an initial historiographical point of departure in Lyotard’s (1984) Postmodern Condition. Lyotard’s (1984) evaluation centres on historical and modernist debates between positivists and phenomenologists in relation to the nature of language, language-games, knowledge, the power inhering in knowledge and the possibility of the acquisition of knowledge (see also Wittgenstein, 1921, 1953; Snow, 1959).Lyotard (1984) recommends an equivocal explication mobilised through a critique of existing forms of grand narrative legitimation (see also Habermas, 1971) and envisages forms of narrative performativity as acts of legitimation in their own right (see also Bauman, 1986). Lyotard’s (1984) main achievement may be said to lie in his privileging of the ‘little narrative’ (Fr. petit récit) - the speaking subjects’ biography - as a form inherently capable of dispelling the problematic question of legitimation by legitimating itself by deemphasising truth-value altogether, a position Sim (2000) terms a move situating the little narrative ‘beyond the criterion of truth’ (p.19). Lyotard (1984) scrutinises the paralogy of positivistic grand narratives and their claims to legitimation: first, ‘the narrative of emancipation, a story of “freeing the people” for which science is believed to be the necessary means’ (p. 13 orig. syntax) and, second, ‘the narrative of the triumph of science as speculation or pure and authentic knowledge’ (p. 28). For Lyotard (1984) an examination of the legitimation of knowledge, and the power obtaining from knowledge, culminate in a conclusion that such claims are founded upon socially constructed misnomers, revealing these claims in actuality to be invariably specious, unnecessary exercises in power enacted through language-games (‘We no longer have recourse to the grand narratives’ p. 60). Lyotard’s (1984) work thus assimilates works by notable post-structuralists preceding his own contribution (e.g. Barthes, 1972; Derrida, 1978; Foucault, 1972; Lacan, 1977; Levi-Strauss, 1963). This singular work can be said to be a clear attempt at situating postmodernism as a paradigm capable of sustaining many perspectives: a more durable theoretical social formation derivable from the fluidity and play of language, the performativity of narrative language, and the possibilities available for multiple social constructions for both narrative culture and narrative identity alike – whilst, acknowledging the significant debt owed to Nietzschean-inspired calls for the broader questioning of the will-to-power and the revaluation of values (Lyotard, 1984: p. 39, 77, 81; see also Nietzsche, 1996, 1998).

Lyotard’s (1984) critical questioning of grand narratives suggests that such dominant narratives are apt to shape subjective conceptions of past, present and future. Narrativist theorists and practitioners influenced by postmodernism have also sought to question the extent to which certain narratives may inhabit a dominant position within the symbolic space of language (e.g. Anderson, 1997; Bannister & Fransella, 1971; Bauman, 1986; Berger & Luckmann, 1967; Freedman & Combs, 1996; Foucault, 1967, 1972; Gergen, 1994; White, 1989; White & Epston, 1990). White (1989) and White & Epston (1990) consider these dominant narratives to provide a compelling frame within which our stories and identities may become subjugated and organised into formations not always of our own invention (pp. 27-8): ‘There exist a stock of culturally available discourses that are considered appropriate and relevant to the expression or representation of particular aspects of our experience … persons experience problems which they frequently present for therapy when the narratives in which they are storying their experience, and/or in which they are having their experience storied by others, do not significantly represent their lived experience, and that in these circumstances, there will be significant aspects of the lived experience that contradicts this dominant narrative.’ We may come to feel that, for instance, certain dominant narratives concerning status, prestige, wealth or happiness become a source of tension if we do not measure up to the ideal (see also de Botton, 2004; Lasch, 1979). Reflexively, I certainly find within myself a good deal of resonance with such insights as these. For instance, my earliest experiences had me partake in a mistaken narrative identity regarding the overriding importance attached to class, ability and academic achievement which, sadly, still catches me out in aspects of my professional life as a supervisor of clinical professionals and sometimes spills over into my personal life in the form of ‘ambitions’ for the young people in my life - though, I am well aware of its origin as my ‘own.’

Vetere & Dallos (2003: 129) provide a synopsis of what they believe may be some principle features of White & Epston’s (1990) therapeutic practices in narrativist work, these are: (§1) exploration of the relevant aspects of lived experience and developing varying perspectives on this; (§2) exploring the connectedness of events and relationships over time; (§3) exploring implicit meanings with exploratory conversation; (§4) identifying those influences which affect the “ownership/authorship” of stories and emphasising the person as a participant in the story with some power re-author that story; (§5) identifying dominant and subjugated discourses in a person’s accounts and the prevailing arrangements of privilege and power; (§6) using different “languages” to describe experience and construct new stories; (§7) mapping the influence of the problem on a person’s life and relationships; (§8) establishing conditions in which the subject of the story becomes the privileged author; (§9) externalising the problem; (§10) recognising unique outcomes. Let us now turn to reportage and critique. First - a general observation - that there appears to be an implicit humanist belief in a continual and universal process of self-actualisation (see also Maslow (1970); Rogers’ (1961: 351f) term ‘actualising tendency’) (see above §1-10). Second, criticism is made against narrativists underestimation of the power of physical groups to create or enforce construing processes, especially in attempts at addressing differences between explicit and implicit storied meanings reliant on internalised others (see below Minuchin, 1998; see above §1-3). Even so, strategic and structural clinical research support a view of people presenting with problems as better understood as largely cases of ‘faulty’ social realities – thus problems of persons’ construing those realities (Haley, 1971; Minuchin, 1974; cited in Dallos, 1991: 58). Third, narrativists support the central importance assigned by other systemic family approaches to dialectic, dialogue, ‘thicker’ storying, linear and circular questions (see also Brown, 1991; Cecchin, 1987; O’Hanlon, 1994; Tomm, 1985, 1988, 1998; Watzlawick, 1978; Watzlawick et al., 2011) (see above §1-8). Four - a general observation – that description is employed at all times in favour of therapeutic prescription or interpretation (see above §1-10). Five, externalising might be understood as serving to distinguish problems or ‘problem saturated’ (White, 1989) stories and/or narratives with ‘the problem’ defining and preoccupying the client in their exploration and mapping and characterisation of self, life experience and relationships. Surfacing and subjugated narratives have also been termed preferred and non-preferred narratives, respectively (Eron & Lund, 1993). Instances where problems may not be in evidence can be extremely useful in this regard and have been termed unique outcomes (Hoffman, 1998; White, 1989) (see above §10). It is noteworthy that the skill of externalising – i.e. linguistic separation of the problem from the self-identity concept – contains within it an assumption of competence, that is, a certain level of cognitive ability with regard to recall, lexicalisation and articulation, which might serve to actually exclude certain cultural groupings because of their individual differences (e.g. persons with learning difficulties, persons with cognitive impairment, persons with speech disabilities, or persons not using their first language) (see above §5-9). The much-admired pioneer of structural family therapy, Sal Minuchin, goes much further in his critique of narrativists. Minuchin (1998) states his disquiet at the prospect of the disappearance of the family from family therapy (p. 397), and the movement of narrativists away from systemic principles (p. 403) in the form of two main questions: ‘Can social constructionism as a meta-theory help family therapists to better understand how families function?’ and ‘Does this theoretical shift imply a new direction for family therapy?’ In his first question Minuchin’s twofold thrust appears to imply that social constructionism is itself a grand narrative by his use of the term ‘meta-theory.’ Moreover, social constructionist practices appear, for Minuchin’s thought, to have located ideology at the expense of dislocating the family in family therapy by ‘tending to privilege the discourse of the individual’ (p. 399). As if in answer to his own second question – i.e. on the prospect of a new direction for family therapy – Minuchin selects the development of multiple descriptions and alternate meanings, concerns with power relations, the linguistic focus, and ‘the use of techniques to enrich the clients’ narrow descriptions of their experience’ for his examination (p. 400). Minuchin (1998) soberly proclaims that ‘in and of themselves’ these are ‘interesting developments’ (p. 403). Even so, Minuchin castigates the narrativists for returning to a traditional individual-based psychological modality for therapy (p. 403). Moreover, the accusation is levelled at narrativists that they are in fact working against the parts of postmodern theory that ‘emphasise social relatedness‘(p. 403). Tomm’s (1998) reply thus agrees with Minuchin’s (1998) analysis where less focus can be placed upon the physical family although, only when viewed from a first-order perspective. Tomm (1998) argues not to have misplaced the family at the expense of ideology; rather he locates the change in perspective as adding significantly to the understanding and work with families in systemic family therapy (pp. 409-10). Tomm (1998) continues by explaining the power differential between both perspectives with precision: ‘A first-order perspective orients us as therapists to intervene directly in family interaction to enable therapeutic change. Therefore it is important for multiple family members to be present. The second-order perspective orients us to intervene in the ways we as therapists see things and into the ways in which family members see themselves, each other and their relationships. Changes in patterns of interaction occur secondarily to changes in patterns of seeing and giving meanings. Consequently, the physical presence of multiple family members is less essential’ (p. 410). What Tomm (1998) encapsulates in these few lines is perhaps the profound power differential between an observed family system (i.e. a modernist perspective of a family system viewed from a place of certainty) and an observing family system, within which a therapist perceives themselves as component of that system (i.e. a postmodernist perspective of a family system viewed and experienced reflexively from a position of safe uncertainty) (Mason, 1993). It is therefore a decisive point to conclude upon, that experiencing the observing system from an internal reflexive position is not of inconsiderable importance – therapeutically and ethically and politically – to the narrativist systemic perspective.

Depression

In the rising dawn of classical literature Aristotle is said to have written within the pages of the Problemata that black bile (melaina kole) was responsible for sapping the ‘exceptional personality.’ Moreover, that this exceptional personality was distinctively characterised by melancholia. And in so doing, Aristotle, if indeed this work can be attributed to him, had also removed melancholia from the Hippocratic notion of the four humors and relocated it back into the heat of nature. This melancholia, then, is not the exclusive disease of the artist, poet or philosopher. Rather, for pseudo-Aristotelian thought at least, melancholia is the very ethos of all humankind. It is, therefore, indeed a titanic legacy born of a phylogenetic inheritance. For the medieval Europeans the idea of ‘genius’ – as a notion separate from our own, appears to have been predicated upon the cultivation of a scholastic, spiritual searching accompanied by anxious torment and pining. That is to say, they extolled and admired the exceptional personality seemingly because it was founded within recognition of the duality and otherness of the Sublime. It was here that the Sublime demanded the suspension of rationality through terror, and the identification of its power through awe in the face of nature’s complexity; between the Cosmos and the Number the medieval European saw humanity as perhaps a potentiality of the alchemical crucible. This may well have been the real philosopher’s stone, that is, the precious ‘gold’ that can emerge from a lowly ‘base metal.’ Now, symbolism, literature and poesis appear to merely make for fine ‘folk psychology’ in the face of a serious matter requiring methodological investigation.

But, that said, let us try to imagine for a moment that one has felt abjection, confusion or a profound sense of loss, or otherwise found one-self as lacking the being most desired, perhaps even hating one-self. One’s thoughts might easily turn to whether one may actually be suffering from so-named ‘depression’ proper. Finding an understanding of a demarcation point between lowered mood and depressive disorder leads us to consider what the signs and symbols of depression might be, and how depressive disorders and melancholia have been historically situated and are currently understood and diagnosed. Broadly speaking, if a person feels so down or deflated, or in lack that they feel a need to do something about it, that is enough to start an investigation. Usually the subject of these forces can experience or present with one or more of the following observable symptoms:

• Exhaustion on waking• Disrupted sleep, sometimes through upsetting dreams• Early morning waking and difficulty getting back to sleep• Doing less of what they used to enjoy• Difficulty concentrating during the day• Improved energy as the day goes on• Anxious worrying and intrusive upsetting thoughts• Becoming emotional or upset for no particular reason• Shortness of temper, or irritability• Loss of sexual appetite or an inability for intimacy

Not all people present with all of these symptoms, and some have different signs or a combination of signs, but if one is suffering with a depressive disorder at least some of these affects will probably ring true. The signs of depression present for the individual - the way that the client ‘feels’ - are used in the diagnosis of depression and/or melancholia. It is, perhaps, easy to see why there is so much confusion surrounding these terms as the symptoms are generally common emotions and feelings among westernised and post-industrial cultures. Only a suitably qualified psychologist, psychiatrist, or GP can formally diagnose a person with ‘clinical depression’, whatever that might be. However, that said, how professionals reach their respective diagnoses provides us with an important insight into how to move forward, and with which suitable treatment. Screening for ‘depression’ is becoming more common, as we begin to realise how much is left overlooked or undiagnosed in our communities.

Most explanatory models of depression focus on behaviour, cognition, biology, and early experience. Most of these models have mentioned the experience of loss as a precipitant of depression. However, none of these models have had very much to say about the contribution of social factors in the person’s environment, or about the broad influences of sex, class, race, culture and life stage. Social models of depression see the cause of the disorder as primarily of social origin (see also Brown, 1989; Brown & Harris, 1978). In other words, depression can be caused by upsetting or unpleasant experiences in the person’s social world. These experiences may be acute life events, such as the loss of a valued friend or partner, or more long term experiences of adversity, such as living in damp, crowded housing conditions for a long period with no obvious hope of ever being able to move. The models considered so far have emphasised the experience of helplessness and the lack of a sense of control over one’s environment as a major cause of depression. It is not difficult to see how certain social conditions or certain social roles can produce a greater likelihood of this experience than others.

Before moving on to consider a specific social model for depression, it is important to point out that the rates of depression differ between certain social groups; these differences do not apply to the bipolar disorders. First, there is a dramatic sex difference in the rates of depression; women are about twice as likely as men to be diagnosed as having major depression (Cochrane, 1983; Weissman & Klerman, 1985). There is no space here to go into all the possible explanations that have been proposed for this difference - many of these explanations are biological, including endocrine or genetic factors. However, biological explanations are undermined by the finding that the sex difference is not consistently found when other, more social, comparisons are made. To give one example, divorced and widowed men have higher rates of depression than single or married women. It is, in fact, only amongst those who are married that the large excess of women over men is to be found (Cochrane, 1983).

Recent research has suggested that having children may be the crucial factor in accounting for the higher rate of depression in women (see also Gater, Dean, & Morris 1989). It is important to point out that the excess of depression in women who have had children is not adequately explained by the occurrence of the mild dysphoria that occurs immediately after childbirth or the more severe postpartum psychosis. The severe and relatively rare disorder of postpartum psychosis occurs immediately after childbirth and appears to have a distinct aetiology linked to biological changes (see also Kumar & Brockington, 1988). Indeed recent research suggests that there is little evidence that women are at increased risk for the more commonly occurring types of depression immediately following childbirth (O’Hara & Zekoski, 1988). It is important to point out that in general women with children are at increased risk for depression when compared to those without children. The problems of selecting a control group to make these comparisons precisely are considerable (see also O’Hara & Zekoski, 1988).

In order to explain the sex difference in rates of depression, it is necessary to look at social explanations, including those that relate to women’s social roles and the stress these roles may cause. Various social explanations have been put forward; these include sex discrimination, the early role socialisation of girls to be more helpless and powerless than boys, the greater acceptability for women in our society to express depression than men. Some sociologists have argued that women’s greater vulnerability to depression lies in the types of roles women are expected to fulfil (see also Gove & Tudor, 1973); roles such as the carer for young children, cleaner, housewife, working mother, etc. The work these roles demand is not highly valued in our society; it is often not paid or poorly paid; there are no fixed hours and generally very poor conditions of service. For many women, especially those who are poor and have few material or social resources, the experience may produce the feelings of being trapped and helpless that are so characteristic of depression.

A well-developed and influential social approach to depression is presented by Brown and his colleagues (Brown, 1989; Brown & Harris, 1978). Over the past twenty years, this research on the social origins of depression has proposed increasingly complex models of the cause of depression and has also implicated the role of social factors in recovery. The approach has many similarities with the other approaches already outlined; for example, the role of early experience is emphasised; a range of vulnerability factors are identified; and specific events are defined which immediately precede or trigger the onset of disorder. The unique contribution of this approach is that all the aspects mentioned are defined in social terms. Adversity in the social world is seen as the cause of the internal changes in biology, cognition and behaviour which are characteristic of depression.

The work of Brown (1989) and his colleagues focuses exclusively on women, but many of the basic ideas about the social causation are likely to apply to men, albeit in slightly different ways due to their different social circumstances (see also Bebbington, et al., 1981; Bolton & Oatley, 1987; Brown, 1989). Earlier research (see also Brown & Harris, 1978) clearly shows that in an inner city sample, working-class women are more likely to suffer from depression than middle-class women. Working women are also much more likely to have experienced a life event with severe long-term threat or a major difficulty. A severe event is one which was considerably unpleasant or upsetting for the women concerned and had a negative threatening aspect which was still evident after about two weeks from the event’s occurrence, for example the death of a parent, child or other very close relative; the loss of a job with no immediate prospect of another one; news of eviction, etc. A major difficulty is an upsetting or unpleasant social situation that has been going on for at least two years, for example very poor housing conditions; chronic, serious illness in a household member; unemployment of the main ‘breadwinner’ in the family. These two types of stressors - severe events and major difficulties - are termed provoking agents. The research showed that these ‘provoking agents’ were much more likely to have occurred in the group of women who had become depressed than in the group that were not depressed. For those women who had become depressed in the past year, 89 per cent had experienced a provoking agent in the nine months before the onset of the depression. In the ‘normal’ group, only 30 per cent had experienced a provoking agent in the same time period (see also Brown and Harris, 1986).

In addition to establishing the importance of ‘provoking agents,’ the model was further refined to include a number of other social factors that were found to be associated with an increased risk of depression, if a provoking agent occurred. These factors are called vulnerability factors and include the following: having several young children at home; not having employment outside the home; and/or lacking an intimate and confiding relationship. Further research has attempted to replicate the above findings in different samples. This research has confirmed the importance of ‘provoking agents’ in preceding the onset of depression. Only one ‘vulnerability factor’ has been consistently identified across these studies, this factor is the absence of a confiding relationship with a partner (see also Bebbington, et al., 1984; Brown, 1989; Campbell, et al., 1983; Parry & Shapiro, 1986). The importance of social support more generally, in protecting against depression in the face of stress, has been the focus of a great deal of recent research; the interested reader is referred to Cohen & Wills (1985) and Cohn & Brown (1989). The social model outlined above, including some of the more recent developments (see also Brown, 1989), can be summarised as follows; vulnerability to depression and the onset of a depressive disorder are regarded as the result of adverse experiences in the environment rather than the result of internal faults, such as those of biology or cognition. Adverse social experiences can occur early in life; one example is the lack of adequate parental care in childhood. This lack of care is then associated with an increased risk of continuing adversity later, such as early pregnancy (see also Harris et al., 1986, 1987). Sex, class, culture and life stage are all important factors in assessing the type of social vulnerability that is likely to be implicated in an increased risk of depression. There is more than one route by which these early adverse social experiences can have their effect (see also Maughan & Champion, 1990). Two examples being: first, the continuation of external stress; second, a negative effect on internal resources such as the adequate development of self-esteem. To give one example of this second route, a failure to establish an adequate degree of self-esteem may make it more difficult to establish and sustain supportive relationships in adult-life; these problems may also increase the risk of experiencing unpleasant and upsetting events in the area of relationships (see also Champion, 1990). It is at this point in discussing the refinements of a social model that it becomes clear that the model is not entirely social, but includes many aspects of the person, such as cognition, behaviour and almost certainly biology and genetics.

Diagnosing Depressive Disorders

According to the definitions of most medical, psychological and psychiatric bodies, there is a commonality of factors in the diagnosis of depressive illnesses. Most tests for depression have a very similar framework. Almost without exception, clinical depression will be diagnosed if a certain number of feelings, that is, signs or symptoms of depression, are present over certain periods of time.

Bio-chemical imbalance: Neurotransmitters

There are in fact five classes of neurotransmitter, one of which is a large-molecule (neuropeptides) and the other four are small-molecules (see also Barker & Barasi, 2008). Some of the neuropeptides are neuromodulators, which is to say that affect the sensitivity of neurons to signals but do not send signals themselves. Endorphins are among the most important neuropeptides because they play a major role in the activation of those systems concerned with pleasure and pain-suppression. Synthesised substances such as opiates (heroin, morphine and opium) affect the same receptors as endorphins. The four small-molecule neurotransmitters are: amino acids, monoamines, acetylcholine and the ‘soluble gases.’ Within mammals the two main concentrations of amino acid found in the central nervous system are gamma-aminobutyric acid (GABA) and glutamate: GABA acts as an inhibitory neurotransmitter, whereas, glutamate acts as an excitatory neurotransmitter. The monoamines are comprised of four sub-classes of neurotransmitter: dopamine (affects muscular control), serotonin (affects arousal, sleep and mood), epinephrine and norepinephrine (together affect emotion and endocrinal systems). Acetylcholine is a standalone neurotransmitter commonly found within the synapses of the central nervous system and the autonomic nervous system. Acetylcholine is suggested to affect memory and learning (Bjorklund & Lindvall, 1986). The ‘soluble gas’ transmitters include short-lifecycle concentrations of carbon monoxide (CO) and nitric oxide (NO2) which are rapidly converted to produce other chemicals or ‘secondary messengers.’

Synthesised drugs affect synaptic transmission by changing the effects of neurotransmitters. ‘Agonists’ is the term used for those drugs which increase the effects of a given neurotransmitter on synaptic transmission. ‘Antagonists’ is the term used for those drugs which block or reduce the effects of a given neurotransmitter. Both agonists and antagonists are divided between those which act directly upon the neurotransmitter and those which act indirectly upon the neurotransmitter. Of these, direct-acting agonists stimulate synaptic receptors, while direct-acting antagonists prevent the neurotransmitter from stimulating the synaptic receptor (heroin is a direct-acting agonist, whereas chlorpromazine is a direct-acting antagonist). Indirect-acting agonists and antagonists change the effects of neurotransmitters but do not affect synaptic receptors (amphetamine is an indirect-acting agonist which increases the release of the given neurotransmitter from the pre-synaptic terminal, whereas parachlorophenylalanine (PCP or ‘angel dust’) is an indirect-acting antagonist which largely reduces serotonin (5-HT) by inhibiting one of the enzymes required for synthesis).

That said, the effects of neurotransmitters, agonistic and antagonistic drugs on neural synaptic transmission and receptivity are considerably more complex and subtle than has been indicated so far. For example, some researchers (Barker & Barasi, 2008; Kandel et al., 2000; Pinel, 1997) espouse that neurotransmitter action often presupposes as many as seven distinct processes, each with a distinctly variable outcome for the effected neurotransmitter within each stage or process. In other words, the implicit suggestion has been made that the affects upon a single neurotransmitter by a single chemical might be subject to up to seven main types of possible variations of outcome, followed by each of these seven main possible variations of outcome being subject to a huge complex of probable variations. In view of these findings one can only wonder at the astonishing complexity of the body’s functionality with reference to synaptic transmission and receptivity. Furthermore, the more often than not successful integration and co-ordination of these neurotransmitters coextensively across the central nervous system, the peripheral nervous system and the endocrinal system, respectively.

Earlier we saw diagnostic health professional’s use guides (e.g. DSM IV) in the diagnoses of depression. Now if we look more closely at point (E), we may recall that it raises an interesting question. It says that clinical depression can be diagnosed if the symptoms cannot be attributed to bereavement. If so, then, since grieving is a natural response we can see that depression might be understood as a ‘natural response’ whose manifestation might be ‘out of place,’ so to speak. In addition, of course depression could well be just that. However, if this were not so, then it seems that we would have to take certain substances to recreate the affects and symptoms. So what about the popular idea that depression is due to some natural bio-chemical imbalance in the brain? In other words, that an imbalance of neurotransmitters lies at the source, and is, perhaps, the root cause of depression. This hypothesis of bio-chemical imbalance is of course quite possible. That point noted however this understanding in isolation requires a much closer scrutiny in the face of substantial evidence to the contrary (found in the majority of clinical caseloads). Simply put, the reason for reticence is perhaps explained when we look at the statistical increase in reports of depressive cases since 1945; here one finds that human brain chemico-physiology does not evolve as quickly as the statistical rise in imbalance suggests. Most depressive symptoms, therefore, are not solely attributable to a bio-chemical imbalance or genetic factors (in fact, research suggests that the genetic predisposition to depression / melancholia only accounts for <15% of cases across <2% general population (or <0.3%). Low serotonin levels, for instance, can therefore be viewed as an effect of an underlying issue – and not simply the ‘cause’ of depressive illnesses. The misunderstanding of over-importance attached to the bio-chemical ‘balance’ may also explain the reason why treatment regimes solely using drugs sometimes miss the point entirely by treating the symptoms or affects instead of the causes (we may recall the wonder-cure called Proxac, for instance). One can surmise then that understanding this issue is clearly another factor toward a fuller clinical understanding of the context of depressive disorders. Put simply, the multifactorial problematic posed by depressive disorders is more vast in its complexity than one can begin to schematise into some simple heuristic.

Depressants

There are several substances which act upon the body and mind as depressants – if one is prone to depressive symptoms large amounts of these substances present a danger to you. These include alcohol, barbiturates (sedatives and hypnotics: such as, barbital sodium, chloral hydrate, methylpentynol etc.) and marijuana (Cannabis sativa/indica). Depressants reduce neural ‘firing’ at moderate doses and above, the action is often to allay anxiety, and with the rise in immediacy of affect so too increases the probability of addiction. Small amounts of these substances typically make one feel less anxious, more relaxed, and less inhibited. In large quantities depressants have a sedative effect, and can make some people more argumentative, anti-social and aggressive. Use of large quantities of depressants can lead to headaches, nausea, sweating and abdominal cramps. Some experience convulsions which can last for several hours. Continued usage of large quantities of depressants (especially alcohol) can also lead to ‘delirium tremens’ (hallucinations, delusions and high temperature). Most habitual among the depressants are alcohol and marijuana. A large quantity of alcohol, for instance, leads to loss of brain neurons and, of course, cirrhosis of the liver. It can also cause severe damage by preventing the liver from metabolising the vitamin thiamine. It is thiamine deficiency which leads to the loss of brain neurons, and this situation produces amnesia or memory loss in the form of ‘Korsakoff’s syndrome’ (i.e. a brain-damaged condition caused by alcoholism and characterised by memory loss and the inability to acquire new knowledge). Regular usage of a large quantity of marijuana also has negative effects, for instance, poor co-ordination, an inability to concentrate, social withdrawal, impaired short-term memory, sensory distortion, blood-shot eyes and slurred speech. Prolonged usage at high-levels has been linked to cardiovascular dysfunction, coughs, asthma and bronchitis (although this may also be linked to the addition of tobacco and nicotine). More serious still is the potential of unusually strong modern strains of marijuana (e.g. ‘skunk’ or ‘super-skunk’) and their growing statistical link to sectioned cases of affective psychoses (bi-polar or schizotypal symptoms). The growing danger presented by the strongest strains of marijuana cannot be underestimated, primarily as the active ingredient, tetrahydrocannabinol (THC), has been measured to contain up to twenty-five (some say thirty) times the THC as found in the ‘older’ species (i.e. sativa) of the plant and its derivatives. Damage to psychological functioning (neurotransmitter and receptor damage) occurs when THC binds itself to the receptors located throughout the brain; these important areas include the hippocampus, cerebellum, the caudate nucleus and the neocortex (see also Devinsky & D’Esposito, 2004; Matsuda et al., 1990).

Categorisation

If one is indeed suffering from a depressive episode or illness a combination of the following vegetative/affective situations, thoughts and feelings may be present or encountered in ones daily life:

• One may feel misery.• One may feel exhausted, a lot of the time apathetic or lethargic.• One may feel as if even the smallest tasks are ‘almost impossible.’• One may seldom enjoy the things that one used to enjoy or over-indulge - one may be ‘off’ sex, or ‘not enjoy food’, or may ‘masturbate excessively’ or ‘comfort eat’.• One may feel very anxious and tremulous.• One may not want to see people or ‘too scared’ to be left alone; social activities may feel ‘hard’ or ‘almost impossible.’• One may find it difficult to think clearly – one may feel as if thoughts themselves are like the horses of a carousel that are moving too quickly to mount.• One may feel like ‘a failure’ and/or feel ‘guilty’ a lot of the time.• One may feel ‘a burden’ to others.• One may feel that ‘life is not worth living.’• One may see ‘no future’ - there is a loss of hope - one may feel ‘all one has ever done is make mistakes’ and that is ‘all that one will ever do.’• One may feel irritable or angry more than usual.• One may feel that they possess ‘no confidence’ or ‘courage.’• One may spend a lot of time thinking about what has ‘gone wrong,’ ‘what will go wrong,’ or ‘what is wrong’ about ones-self as a person. One may also feel ‘guilty about speaking critically of others’ (or even ‘thinking critically about them’).• One may feel that ‘life is unjust,’ and that ‘the world is personally persecuting me.’• One may have difficulty sleeping, or wake up very early in the morning and cannot return to sleep again. One may seem to ‘dream all night long’ and sometimes have ‘disturbing dreams.’• One may feel that ‘Life’ is ‘passing them by’ – one is ‘merely a bystander.’• One may have physical aches and pains which appear to have no physical cause (psychosomatic pain).

Thus it is in the wealth of these all-too-common depressive signs and the broad scope of neuro-transmitter affectation that appears to confuse many people as to how and what depression actually is. Explanations rarely cover all the symptoms mainly because everybody’s experience of depression is different and unique to them. And this is another important point when we begin to think clinically about depression; every depression is unique, although it may be framed by some overall understanding of the pattern of the affective symptomology at hand.

SEASONAL AFFECTIVE DISORDER (SAD): If one becomes depressed only during the autumn and winter, it could transpire that this is due to not getting enough daylight. Sufferers of this condition can benefit from spending some time each day in front of an especially bright ‘light box.’

POSTNATAL DEPRESSION: Many mothers experience ‘the baby blues’, as they are sometimes called, soon after the birth of their baby. This can often pass after a few days. However, postnatal depression is a much more serious problem and can manifest itself anywhere between two weeks and two years after a birth. There is a significant risk of self-harm or deliberate self-harm (DSH).

MAJOR DEPRESSION: Major depression is probably one of the most common forms of depression. One may know a handful of people who suffer from it as it has been said that one in five people from the westernised-industrial cultures suffers from it. The sufferer seems be flooded by the weight of the problems on his or her shoulders. S/he seems disinterested in becoming involved in regular activities and seems convinced that s/he will always be in this apathetic situation. There is a lack of interest in mutual sexual intimacy, or in appetite, and often accompanies a significant gain in or loss of weight. There is a significant risk of self-harm or deliberate self-harm (DSH).

ATYPICAL DEPRESSION: Atypical depression, sometimes known as ‘smiling depression’, can be seen as a variant of depression that is slightly different from major depression. The sufferer is sometimes able to experience happiness and moments of elation. Symptoms of atypical depression include fatigue, oversleeping, overeating and weight change. People who suffer from atypical depression believe that external events control their internal mood (i.e. success, attention and praise). Episodes of atypical depression can last for months or a sufferer may live with it for their entire life without ever knowing why.

PSYCHOTIC DEPRESSION: Sufferers of psychotic depression begin to hear and see imaginary things, such as, sounds, voices and images that no-one else can witness. These are referred to as hallucinations or delusions, which are generally more common with someone suffering from an affective schizophrenia. The delusions are not as positive, so to speak, like they are with manic depression (see also below). The sufferer of psychotic depression imagines negative sounds and images which do not merely provoke persecutory anxiety – they are, in fact, both terrifying and petrifying. There is a very significant risk of self-harm or deliberate self-harm (DSH).

DYSTHYMIA: Many people go about their daily lives seemingly depressed, that is, simply sad or down. They have been this way all of their lives. This can be called dysthymia - a condition that people may not be even aware of but live with daily. They go through life feeling unimportant, dissatisfied, frightened and often do not enjoy their lives. Some medications can be beneficial for this type of depression as it may be caused by bio-chemical neurotransmitter imbalance.MANIC-DEPRESSION OR BI-POLAR DISORDER: Manic depression, as it was once known, can be defined as an emotional disorder characterized by extreme changes in mood or personality characterised by an oscillation between episodic cycles of depression (lows) and mania (highs) whose rhythms must be monitored. The rhythms of this oscillation can vary from days to months. People who suffer from bi-polar disorder (more correctly) are at very high risk of deliberate self-harm (DSH).

Albrecht Dürer (1471-1528) was considered an artistic genius during and after his lifetime. The picture above, Melancholia & I, is an engraving dating from 1514 CE. Melancholy herself is here depicted as surrounded by the instruments of her medieval temperament. The bat-like creature flying through a night sky declares the subject of this famous engraving - Melencolia I. The darkened temperament is personified by a female figure seated in the foreground. The winged infant beside her is a ‘genius’ - in the medieval sense, meaning an accompanying spirit, homunculus or familiar. Melancholy is possessed of wings, and from her belt hang keys and a money bag, these symbolise her intellectual capabilities, power and wealth, respectively. She is surrounded by measuring instruments. Above her head is a panel of ‘magic’ numbers, as they add up to thirty-four in all directions. At her feet are the tools that can fashion the furniture of the material world. Yet, she does nothing; she is lost to thought, she shuns the light and embraces the night-side of her countenance. As I began by saying, the renaissance philosophers of Europe had suggested a new interpretation for melancholia, as the temperament of the exceptional personality. Melancholia was possessed by artists, poets and philosophers in whom imagination and creativity predominates. Reason, it was said at this time, merely dominates scholars, while the final and highest stage of Being was seen as Spirit or Soul which was the preserve of the philosophically minded. So here then, the much renowned Dürer may be suggested to be actually presenting us with a type of self-portrait taken from his temperament rather than his appearance.

‘There is but one serious philosophical question and that is suicide,’ writes Albert Camus in his existential study, THE MYTH OF SISYPHUS. 1942. Suicide is, for Camus at least, an indicator of the absurd, an sign of the absurdity of the times in which we find ourselves, for instead of remembering that melancholia was once held up as a personification of the imaginative and the creative powers inherent within the renascent mind, it is often met with misunderstanding and its sufferers almost inevitably marginalised to some degree. Nevertheless, how did this situation come to be so? For Foucault (MADNESS & CIVILISATION, 1967), one of the radical historians of ‘madness,’ the central overarching answer to this complicated question remained that: “madness is the déjà-la of death.” Here Foucault is suggested to point to a meta-proposal that ‘abnormality’ reminds the so-called ‘sane’ of their own mortal frailty, and, thus, in that moment of frailty before the Other; a torsion between superiority and anxiety, the natural consequence is a call to flight. Any more concrete answer to the plight of the fragmented is more opaque than transparent, or at least too ambiguous to lead one closer to some form of positivism with regard to a truth to be applied in some wholesale fashion. Nevertheless this actuality does not intend for melancholia to renounce herself as an object for more intensive future ‘scientific’ study – on the contrary, one ought to say that some greater clarity on the natural science and the pure psychology of depressive disorders is much needed.

Perhaps alongside the rigorous research movement toward the how and what of ‘depressive disorder’ the why will be further incorporated alongside the practical consequences of those research studies which have also begun to quite recently emerge on the not dissimilar, and equally problematic, subject of CONSCIOUSNESS. It is not inconceivable to imagine the why to either as betraying itself somehow as lying between the orders of consciousness and melancholia; one could suggest there existed a considerable overlap of phenomenological significance. Which is to say, just as consciousness assumes that consciousness be a conscious determination of some-thing; so too, depression and melancholia also assume an over-determination of some-thing upon consciousness. Furthermore, if one further imagines these identifications (images, ideas and representations) in phenomenological terms of significance (determination) and over-significance (over-determination), one can begin to approach a more satisfactory realisation through a careful archaeology of the concave impressions of the lack.

Anxiety

Schopenhauer was utterly convinced by his fireside musings on the nature and source of the abnormal anxiety. For Rosenhan (1973), on the other hand, the critical question was the undeniable lack of falsifiable evidence for a contradistinction at all given that the notion of abnormal rests entirely upon knowledge of what is ‘normal’. For many clinical professionals there is a distinct lack of certainty on the nature or location of the threshold between the ‘normal’ and the so-called ‘abnormal.’ Of course, there are many ways in which one might come to an understanding of what might constitute ‘abnormality’ or ‘abnormal behaviour’ based on social norms.

Never the less a clear paradox surrounds the notion of social norms; behaviour in one culture may not be viewed as such in another setting or indeed another time. One method of quantitative statistical analysis (and the pure natural sciences more generally) is to represent the abnormal, or standard deviation, as rare within a population (i.e. typically around +/-2 standard errors from the standard mean). For example, if one were to use Spielberger’s ‘State-Trait Anxiety Inventory’ assessment criteria, then the mean score is set at forty (40), and only 2% of people score higher than fifty-five (55). Here then, for Spielberger, abnormality is viewed as statistically rare within a general population (<2%). However, merely citing the statistical rarity of ‘abnormality’ is neither sufficient nor adequate to the task of its causal understanding. The statistical approach takes no account of whether negative or positive deviations from the ‘normative position’, (say, a score of 40), have any meaningful qualitative measure of valuation. In other words, can we say anything meaningful about the relation between a score of 20 when compared to a score of 55? Are these people simply ‘mad’, in opposition to the normal score seen as ‘sane’ or just different? Moreover, if these people are considered to be ‘mad’, then by what standard can ‘madness’ be further understood? Some have said that there are three main features which characterise pathology – the so called three ‘D’s: Distress, Dysfunction, and Deviance.

Rosenhan and Seligman (1989) have claimed that there are seven main features to ‘abnormality’: suffering, maladaptiveness, vividness and unconventionality, unpredictability and loss of control, irrationality and incomprehensibility, observer discomfort, and violation of moral and ethical standards. Nevertheless, one’s attention ought to be drawn towards whether an individual can be said to be determined as understood through the subjective judgments of others. That is, judged when the reaction of one may not be repeated by the reaction of another. Let us recall the hard lesson taught to us by homosexuality: only ceasing to be categorised as a ‘mental disorder’ as recently as 1980. Further, clinicians are advised early in their training to slow themselves in attributing judgments of abnormality, especially so when the matter of normality is very far from finalised to any satisfactory extent.

Strange as it may sound now, anxiety disorders only became formally recognised by medico-psychiatry (also in 1980) through the American Psychiatric Association’s influential handbook, Diagnostic and Statistical Manual of Mental Disorders (also known as DSM). Although anxiety disorders have been only recently officially recognised (in Britain we use the American editions of DSM IIII and IV alongside our own ICD-10) the disorders in question have certainly existed throughout the written record.

Throughout written history many individuals have experienced anxiety, panic attacks or a profounder fear in some form or another. The various treatments that people have received over time can be called diverse, dangerous and sometimes even laughable. ‘Treatments’ that were popular throughout history include: the application of balms or the imbibing of various herbal tinctures; mineral health spas; hydropathy, that is the application of extreme water temperatures to the body through total immersion; animal magnetism or ‘mesmerisation’ as used by Franz Mesmer (1734-1815) and Amand-Marie-Jaqcues de Chastenet, Marquis de Puységur (1751-1825). And, of course, let us not forget the use of trepanning, that is drilling holes in the subject’s skull (thought to relieve pressure), blood-letting through the application of leeches, and even exorcism (its earliest beginnings as a shamanic rite which aimed to dispel the malevolent ‘spirits of the forest’) through to such notables as the extraordinary Fr. Johann Gassner (1727-1779) who, incidentally, became famous across the royal courts of Europe for his ‘Exorcismus Probativus’ or ‘Trial exorcism’.

Before the recognition of anxiety by the field of dynamic psychiatry - dominated by such names as Charcot (1825-1893), Bernheim (1840-1919), Janet (1859-1947), Kraeplin (1856-1926), and Bleuler (1857-1939) – people experiencing one of these debilitating disorders usually received a generic diagnosis of ‘stress’ and/or ‘nerves’, and thence usually told to take ‘a convalescent break.’ It can be said, therefore, that there was, certainly until WW1, relatively little acknowledgement of anxious disorders outside of psychoanalytic psychology. It (psychoanalytic thought) acknowledged this problem as a problem as early as 1893 (cf. Freud’s correspondence with Wilhelm Fleiss / Freud and Breuer, Studies on Hysteria, 1895). As a consequence of this lack of recognition very few people received an effective treatment in the early years of psychiatry. With the dawn of ‘the talking cure’ however, as it became known, many people turned to as the psychotherapist’s office as it became the preferred cathartic option to experiences of anxiety disorders. That said, since the end of WW1 increasing amounts of international research showed that severe anxiety dysfunctions, such as ‘shell-shock’, now better known as post-traumatic stress disorder (or ‘PTSD’) are associated with the disorders stemming from ‘extreme emotional trauma.’ Alongside this research into the terrible affects and behaviour patterns linked to the conditions of soldiering, the continuing appraisal and reappraisal of Freud’s original thoughts, that is, what he originally called ‘hysterical anxiety’, continued to find an increasing audience within psychiatry (cf. Freud and Breuer, op. cit., 1895). We will recall that Freud characterised hysteria as appearing as either, (a.), Conversion hysteria – in which psychical conflict is expressed in somatic symptoms paroxystically [emotional crises accompanied by theatricality], or (b.), Anxiety hysteria – as a more long lasting form where the anxiety is attached to a specific external object as a phobia. The dysfunctions which appear under the heading of anxiety and stress are many and can include: agoraphobia, low self-esteem, irritability, substance misuse, self-harming behaviours, deliberate self-harm (dsh), and various forms of mood related depressive states – which, in particular, we will speak of in another seminar. More recently, then, there has been a swell of media interest in the prevalence of anxiety, panic attacks and anxiety disorders within westernised societies – in fact, recent studies suggest that one in five will suffer from the affects of anxiety disorders during their lifetime. Of course, that said, one might recall Carl Jung, the analytical psychologist, as one probably have held it true that during what he named as mid-life crisis we are all subject to an anxiety based upon our consciousness of our status in relation to our expectations for our own individuation (as if an actualising need for our further individuation prior to the onset of death). Others, such as Ludwig Binswanger, the existentialist psychologist, would have described the crisis at hand as one of existential angst, that is, the all-too-human anxiety provoked by our situation as beings thrown (like clay on the potter’s wheel) into the world. In this situation of thrownness we are viewed as the only inauthentic animal. In other words, we are viewed as the only known conscious being which knows of our own mortality, and then able to communicate this concern to other likeminded conscious beings through the medium of language. The phenomenologist, Martin Heidegger, in particular, develops a phenomenological framing of existential concern with his notion of the Human as a peculiarly conscious being conscious (Ger. Dasein) and a being marked as a Being-towards-death. Here Heidegger exposes ontological and temporal points to an astonishing detail, and with astonishing results, in his masterwork, BEING AND TIME (1927).

Notwithstanding the existential nature of angst, as more people become aware of the presence of anxiety disorders so increased the interest in finding an appropriate clinical response to treat these most human of anxiety related disorders. As a consequence anxiety disorders now carry less of a stigma as more people from all walks of life present to their health professionals for the treatment of these conditions. That said this was not always such a smooth succession. It was the common thought in the very recent past - actually less than one hundred and fifty years ago - that anxiety disorders and panic attacks were seen to be exclusively a women’s problem; and by that measure it was presumably linked from menstrual cycles back into Eve’s own mythic transgression. One psychiatrist of the mid eighteenth century, Dr. Mobius, even went as far as to claim that the biological development of women should be understood to exist at the mid-point between that of children and men! To this misguided atmosphere, Freud, and to some extent Charcot, are perhaps also guilty of this type of misogyny. But, to be fair to both, such sentiments are products of their own time. The call for feminine inferiority was certainly unfounded; the awful experiences of shell-shocked young men returning from the First World War trenches finally put pay to those gender-based conspiracies of nonsense. The reason for this misnomer then, perhaps, may lie in the situation that men are seen as more hesitant to present for the treatment of anxiety issues. However, the actuality of the situation remains that both women and men are affected similarly by these disorders. With the advent of contemporary pharmaceuticals, powerful drugs are prescribed in increasingly large numbers for people presenting with an anxiety disorder. Some might observe that we are reaching a ‘take two of these’ mentality with regard to anxiety and its associated dysfunctions within some GP surgeries. And this observation does have some credence as, in 2005, for instance, the ODPM (Office of the Deputy Prime Minister) sent an advisory letter to GPs nationwide strongly suggesting for them to effectively slow down the issuing of certain prescriptive anti-depressant medications.

It is therefore with a multi-factoral approach strictly to the fore that we can now attend to the theories of anxiety (including stress). Simply put, the position put forward here is that any comprehensive understanding of anxiety would aim to propose a theory which answered those questions arising from each of the cardinal theoretical stances found within the broad church of clinical psychology. The notion of retaining objectivity had been put forward by Sandor Ferenczi (1926) on account of clinical observation and empirical testing, together. Ferenczi’s chosen term for the concept of adopting an inclusive approach toward ‘pure psychology’ and ‘pure natural science’ alike was ‘utraquism’ (derived from the sixteenth century protestant sect the ‘utraquists’).

• Bio-physiological (pure natural science) theories of anxiety

Clearly, it is not possible to look at anxiety without acknowledging the role of neurobiology. However, it is considered by those concerned with bio-physiological interpretation to be the primary factor in understanding the origin and maintenance of anxiety. Eysenck (1967) is well-known for his proposal for a biological theory of personality, based on different levels or intensities of cortical arousal (that is, endogenous arousal stirred up by exogenous stimuli).

• Behavioural theories of anxiety

Behavioural theories of the acquisition and maintenance of anxiety are based on theoretical explanations of how we learn (see instrumental conditioning – i.e. ‘learned helplessness’).

• Cognitive theories of anxiety

Cognitive theory claims that the primary factors in the origin and maintenance of anxiety is the thinking ‘process.’ According to this theory, it is the way an individual appraises a situation and thinks about it that determines the emotional and physical response to that situation (for instance, ‘expectancy’). Here it is argued that two people can experience the same condition, yet it affects them each differently.

• Psychodynamic (pure human science) theories of anxiety

Psychodynamic theories are concerned with the objects which occupy the inner and the outer world experience and the dynamics of objects which govern relations between the orders of internal and external reality. Psychodynamics holds to the view that some of the imaginary objects are repressed, which is to say, an image or idea has been censored and kept unconscious as a primitive defence in the service of self. Repression and transference are both deemed as ubiquitous human functions which can be positive as well as negative. Anxiety is said to occur when one finds it difficult to cope with one’s thoughts and feelings when external demands or internal objects/impulses represent major threats to psychic equilibrium. The feeling of anxiety is triggered (signal-anxiety) in the present by various associations to past experience. It was Freud who had first stated that missing something which is longed-for may be a key toward an understanding of anxiety. For example, how else are we to explain the connection between early loss or separation - though not consciously remembered – and the increased likelihood of appearances of anxiety in later life?

Neurasthenia

Neurasthenia is characterized by general lassitude, irritability, lack of concentration, worry, and hypochondria. The term was introduced into psychiatry by the neurologist Dr. G. M. Beard in 1869, and it is not the same as Anxiety Neurosis, at least according to Freud – but we shall come to this distinction presently. Neurasthenia, then, covers a wide spectrum of symptoms, including painful sensations or numbness in parts of the body, chronic fatigue, anxiety, and fainting. To the thought of some medical historians, they believe that neurasthenia may actually be the same as the modern day disorder of chronic fatigue syndrome [M.E.]. Neurasthenia is also known as: Primary Neurasthenia, Cardiac Neurosis, Chronic Asthenia, Da Costa’s Syndrome, Effort Syndrome, Functional Cardiovascular Disease, Soldier’s Heart and Subacute Asthenia.

Diagnostic criteria for Neurasthenia include (cf. DSM IV):

• Persistent and distressing symptoms of exhaustion after minor mental or physical effort including a general feeling of malaise, combined with a mixed state of excitement and depression• Accompanied by one or more of these symptoms: muscular aches and pains, dizziness, tension headache, sleep disturbance, inability to relax and irritability• Inability to recover through rest, relaxation or enjoyment.• Disturbed and restless, un-refreshing sleep, often troubled with bad dreams or nightmares• Duration of over three months (>3mths)• Does not occur in the presence of organic mental disorders, affective disorder, panic or generalized anxiety disorder

Sub Types include:

• Cerebral. – Headaches are the prominent symptom. Insomnia is quite characteristic, and the subject rises tired and quite unrefreshed, there is more or less a general despondency, the subject is anxious, worried, and fearful, anxious of some conceived impending danger. A continued tired feeling is generally present.• Spinal – Backache, with tenderness along the spine, is characteristic. Other manifestations may include tingling, crawling, or burning sensation, or certain parts will feel hot or cold.• Gastro-Intestinal – Gastric disturbances are the chief characteristics of this form. Hypera-cidity, nausea, retching, and vomiting. The subject sleeps poorly, has unpleasant dreams, and develops an irritable disposition. There is flatulency, rumbling of the bowels, consti-pation may alternate with diarrhoea and a sense of weight or soreness over the abdomen.• Cardiac – While there is no organic reason, the person may experience palpitations and sometimes sharp pain similar to angina.• Urinary – The quantity of urine expelled is usually small. The subject becomes irritable, and experience dull headaches.• Sexual – A fear of becoming impotent preys upon the mind, the subject is depressed, sleeps poorly, has nocturnal emissions, complains of pain or crawling sensations in the testicles, has perverse sexual desires, and masturbates frequently and often excessively

Some disorders have similar symptoms, most notably anxiety neurosis. The psychologist or psychiatrist, therefore, in their diagnostic attempt, has to differentiate against the following disorders which need to be ruled out to establish a precise diagnosis. Many medical disorders can cause fatigue, therefore, a thorough medical examination, and/or review of medical history is necessary and often aids the clinician greatly.Causation:

The cause of Neurasthenia remains unknown, however, like most disorders certain predisposing factors may play an important part, chief among these may be mentioned heredity factors, occupation (‘high stress’ occupations), age (tends to occurs between 20 and 55 years of age), and gender (predominantly seen in males).

Hysteria

The notion of a hysterical disease is very ancient indeed, in fact, it dates back to the first known person to demarcate between philosophy and medicine, Hippocrates of Cos (c. 469-399 BCE). Therefore, one can say that hysteria is probably as old as medicine itself. That said, and altogether much closer to our own time, toward the end of the nineteenth century, particularly, through the neurological work of Charcot at the Salpêtrière in Paris, here the status quo of a gynaecological psychogenesis for hysteria was challenged. On the one hand, and in the lack of any organic lesion, hysterical symptoms were treated as if they were thought to be the result of suggestion or auto-suggestion. On the other hand, hysteria should be raised to the status of a disease (following Charcot) as its symptoms could be as well defined as any other neurological condition. The approach developed by Breuer and Freud allowed them to explore a third position for hysteria. Freud, a student of Charcot’s teaching, looked upon hysteria as a definable psychical dysfunction requiring an explanation in terms of a specific aetiology. It is during this period of time that Freud simultaneously made his principal discoveries and, possibly, his greatest failure: he arrived at the notion of the unconscious, the notion of the role of fantasy, defensive conflicts and repression, identification, and transference, but he also aligned himself with those who saw hysteria as a malady through representation with the penis. In other words, regrettably, a malady brought about by the lack of the penis in women. And so was born the impractical notion of penis envy; one can say impractical as any time spent in the company of men teaches us that their own curiosity and anxiety directed toward the vagina may easily be seen as of equal consequence to psychology – but do we speak of vaginal envy? Perhaps not explicitly. Nevertheless, Freud’s “useful fictions” have provided a framework for contemporary psychoanalytic thought and dynamic psychiatry alike as hysterical neurosis (as paroxystic) and obsessional neurosis (as phobic and ritualised) came to be establish the two main divisions within the field of mental illness known collectively as the neuroses.

Anxiety neurosis

In an article of 1895, Freud distinguished anxiety neurosis from neurasthenia because of the predominance of anxiety, symptomatically speaking, exampled by chronic anxious expectation, attacks of anxiety, or of its somatic equivalents. He also distinguished anxiety neurosis from hysteria, aetiologically speaking, because he held that anxiety neuroses is an actual neurosis characterised by the accumulation of sexual excitation which, in turn, he held to be transformed directly into symptoms without any psychical mediation required. The term he uses for this natural process of energetic transformation he called sublimation. The abiding legacy of this period in Freud’s work was his complete conviction that the energy behind the human condition, the so-named libidinal energy, or libido, was an ancient phylogenetic inheritance of an instinct (he actually used the German word trieb which is closer to drive) to survive by instinctual reflex. In this view, the need for people to build homes to live in, create pottery to eat from, or even socialise and create language and literature are sublimations of an original drive toward a continuance of life over death. Interestingly, to Freud’s view someone like Leonardo da Vinci, though great by any standard, is seen as a sublimating male driven to creativity by unresolved sexual tensions (sublimation). It is, therefore, easy to understand common-sense objections to this thought, even though the reasoning behind the thought is actually quite rational, considered and nuanced. That said, in the ‘return to Freud’ a highly specific view on the aetiology of anxiety can be seen, and one can discern two main associations: the first, that, anxiety is caused by the accumulation of sexual tension, and secondly, that, the absence or insufficiency of bodily sexual excitation can only be transformed into psychical libido, that is, successfully sublimated, on the condition that it be connected to a pre-determined group of sexual ideas. He attempts to demonstrate this theory by the examples of virginal anxiety, anxiety as a result of abstinence, of ciotus interruptus, and so on. Moreover, he goes on to draw attention to a similarity between hysteria and anxiety, in that in both terms, he writes: ‘there is a kind of conversion; but in hysteria it is a psychical excitation that takes a wrong path exclusively into the somatic field, whereas [in anxiety neurosis] it is a physical tension, which cannot enter the psychical field and therefore remains on the physical path. The two are combined extremely often’ (Freud, STANDARD EDN., VOL. 1: p. 195)

That having been said, Freud never abandoned his position on the specificity of anxiety neurosis as an actual neurosis contradistinctive from either hysteria or neurasthenia. One will recall that to Freud’s 1920’s thought the Oedipus complex finds resolution through the threat of castration anxiety. That is, the boy-child seeks the symbolic death of the father, as main rival for the greater attentions or symbolic seduction of the Mother. But the boy-child symbolically assumes in unconscious fantasy that the punishment for this transgression to be nothing less than castration. Thus, the resolution for this situation is clear for Freud – the boy-child must renounce his symbolic claim for his Mother and find someone else to invest his sexual energy with. In 1923 Freud introduced the concept of the superego as ‘the heir to the Oedipus complex’ to account for the internalization of parental values that accompany the resolution of the oedipal struggle. In this way, the superego mediates over the powerful urges of the id to greater strengthen the reality function of the ego. By holding this view Freud is also stating that males value both the real and the symbolic phallus, as the organ of drive satisfaction, above all other objects. He holds to an assumption that everybody must have access to the power of the phallus, so to speak. And it is in the recognition of anatomical difference that a prevailing fear endures throughout life: the fear of humiliation and feminisation by castration. For Freud, the same is true of women; it is in the shock of the discovery of anatomical difference that leaves them feeling symbolically castrated, powerless and insecure. Women, to Freud’s thinking, long for penis substitutes, such as in a healthy situation a baby. Only in this way, continues Freud, are women able to cope with the psychological difficulty of their biologically dictated role within society. For Melanie Klein the idea of libidinal phases for development needed reorganisation. Klein went about her task of maintaining the primacy of sexual drive but, saw it as deriving from a phantasy struggle to integrate Love and Hate (Eros and Thanatos) within the paranoid-schizoid and depressive positions. Klein could not agree with Freud that reproduction was a manifestation of ‘phallic intactness’ for males and ‘narcissistic compensation’ for females. For Klein, then, reproduction suggested itself as proof that something good could emerge from inside despite the presence of destructive feelings to the contrary: there was room to consider that good internal objects were as viable as bad external objects. In other words, Klein felt the call to demonstrate an acquired ambivalence (as the ‘Depressive position’) in the face of ‘splitting’ experiences of the internal and external world as nothing less than crucial to emotional development (see also Winnicott 1967; Bowlby 1971).

Anxiety disorder

Anxiety disorders may cause people a number of different physical and psychological problems. Some people suffer from anxiety all of the time – this is called generalised anxiety. For people suffering from panic attacks, the symptoms of anxiety are likely to come out of the blue. Another sort of anxiety disorder is called a phobia, in which people have problems in certain situations. Post-traumatic stress disorder (PTSD) is another form of severe anxiety. The psychological symptoms of anxiety include feelings of dread and irritability, and increased muscle tension and activity of the nervous system. This leads to a variety of physical symptoms such as dry mouth, shortness of breath, dizziness and trembling. Anyone can have feelings of anxiety. These may occur in response to a stressful situation. Sometimes these feelings can be helpful, for example, by increasing a person’s ability to perform in a race. These feelings are normal. Only when the symptoms are more intense or long-lasting do they interfere with a person’s concentration and ability to do routine tasks. People may avoid situations that could provoke feelings of anxiety. This interference with daily living, as much as the symptoms themselves, may lead a person to seek help. Anxiety disorders are quite common, affecting 5% of the population at any one time, but many people do not seek help. More women than men are affected. Anxiety disorders often start in their early 20s - but may begin earlier. Less often anxiety occurs in the elderly.

Causes

Causes are not always so clear. Anxiety disorders are more common in some families, suggesting that genetic factors may be important. These disorders may also develop as a result of emotional or social problems, occasionally starting after a stressful or frightening event. One theory is that some of these problems are caused by ‘faulty’ thinking. For instance, an exaggerated fear that physical symptoms (such as palpitations) together with the feeling of anxiety, will lead to a medical emergency. Someone having these palpitations and feeling his heart beating a little fast may believe that he is going to have a heart attack. This may lead to increasing levels of anxiety, and even more palpitations.

What treatment is available?

The aim of any treatment is to try and help someone to reduce their symptoms of anxiety to an acceptable level, so that the anxiety no longer interferes with day-to-day living. Health professionals can help by giving a clear explanation of the symptoms. The doctor may point out that physical and psychological feelings are closely related. For example, breathlessness or dizziness can occur in anyone feeling under stress, and do not necessarily mean that there is a serious disease in the rest of the body. Health professionals may also encourage a person to try and identify any social or emotional problems. There are various ways of trying to deal with these, but one helpful approach can be to use problem-solving techniques. These can be complex or as simple as listing the problems and selecting one for action. Different approaches are then looked at, their pros and cons reviewed, and finally the best course of action chosen. Problem solving can be a self-help technique or may form part of a course of therapy sessions, either on a one-to-one basis or in an anxiety management group. It also naturally forms part of relationship based psychotherapy that can sometimes be helpful.

Stress

The term ‘stress’ appears at first (Selye, 1950) to signify “the non-specific response of the body to any demand.” However, the generality of this high-level definition assumes a linear causation of factors underlying stress. For Cox (1978) stress depends more on an interaction (a ‘transaction’) between the individual and their environment. This lead many including Steptoe (1997: p. 175), to redefine ‘stress responses’ as those “said to arise when demands exceed the personal and social resources that the individual is able to mobilise.” For example, a learner driver can feel overwhelmed by the limitations of their abilities to manage a car in busy traffic. Many argue that most, if not all, of our human emotions have evolved because they are adaptive and functional in some way. Thus, a little stress has been argued to not always a bad thing, it may demand of us that we reach deeper than usual into our inner resources. In contrast, it is also clear that ‘stress’ has some very damaging long term effects (see Baxter, 1980; Carlson, 1994; Cohen, Mason, 1975; Selye, 1950; Symington, 1955; Tyrell & Pinel, 1997; Tyrell & Smith, 1991;). Many of the effects (and affects) of stressful living are both physiological (somatic) and psychological (psychical) in nature. Selye’s (1950) psychosomatic theory of and for stress is called the General Adaptation Syndrome. Here the bodily responses to stress are thought to consist of three separate stages: Alarm reaction, Resistance and Exhaustion (eventually the physiological systems used in the Alarm and the Resistance stages become ineffective and stress-related diseases - such as, high blood pressure, digestive problems, asthma and heart disease – become more likely. These finding of increased cardiovascular and gastric illness were later evidenced by Pinel (1997). Holmes and Rahe (1967) famously devised the Social Readjustment Ratings Scale to account for findings that suggested many illnesses had been preceded by the experience of several major (stress response invoking) life events. According to Holmes and Rahe (1967) any ‘changes’ (positive or negative) can be stressful (for example, a holiday carries a score of 13 points, minor violations of the Law carry 11 points, death of a spouse carries 100 points and divorce carries 73 points. Further evidence, unsurprisingly perhaps, also suggests that people who have experienced events totalling more than 300 points (on the social readjustment scale) within the period of one year are demonstrably more at risk from physical and mental illness (Martin, 1989; Tache et al, 1979).

It is noteworthy that Barlow et al. (1986; cf. in Michael Eysenck’s PiP (2004) p.834) found that a significant number (66%) of patients suffered from more than one anxiety disorder.

1. PANIC DISORDER

DSM-IV defines a panic attack as the sudden appearance of intense fear or discomfort with four or more bodily symptoms (e.g., palpitations, accelerated heart rate, nausea, sweating). This condition is often accompanied by agoraphobia, the fear of leaving the house in case a panic attack occurs in a public place.

Crowe et al. (1983) found that panic disorder occurred in almost 25% of close relatives of sufferers (compared with a 2% rate in the general population).

Genetics contribute to personality and those high in anxiety sensitivity are far more likely to suffer panic attacks than those low in anxiety sensitivity.

Cognitive model

Those with panic disorder make cognitive misinterpretations of a situation (cf. in Michael Eysenck’s PiP (2004) p.835). They tend to exaggerate the implications of such bodily sensations as an increase in heart rate, perhaps because of childhood experiences of inability to breathe properly.

Verburg et al. (1995; cf. in Michael Eysenck’s PiP (2004) p.835) found that 43% of adult panic attack victims had some history of respiratory disease compared to 16% of people suffering from other anxiety disorders.

Social factors

Panic disorder may be related to the occurrence of adverse life events, e.g., family problems, in the preceding few months (Barrett, 1979; Kleiner & Marshall, 1987; cf. in Michael Eysenck’s PiP (2004) p.835).

2. POST-TRAUMATIC STRESS DISORDER (PTSD)

PTSD is an anxiety condition that occurs after experiencing some traumatic event. The condition is worse if the event is life threatening and the same event will trigger PTSD in some individuals but not others.

Foy et al. (1987; cf. in Michael Eysenck’s PiP (2004) p.836) suggest that the likelihood of PTSD, as other disorders, depends on an interaction of genetic vulnerability and the severity of the event, correspond-ing to the DIATHESIS–STRESS MODEL. However, in contrast to other disorders, if the trauma is very extreme then the condition is liable to occur even in those who are not at first sight genetically vulnerable or predisposed to the condition.

Psychodynamic model

Horowitz (1986) suggests that traumatic events are so overwhelming that they are repressed, but since they have not been dealt with they eventually cause symptoms of PTSD. This does not, however, explain individual differences in susceptibility to a particular harrowing event.

Behavioural model

This is explained in terms of classical conditioning of fear (cf. in Michael Eysenck’s PiP (2004) p.837). By ‘CC’, the individual becomes terrified of anything that was associated with the event (including smells, noises, etc.) and desperately attempts to avoid such reminders since this reduces anxiety. Avoidance of anything associated with the event is therefore operant conditioned. This explains why some triggers are very upsetting but, it does not explain individual differences in susceptibility, and, nor does it explain why PTSD develops rather than another specific phobia.

3. SOCIAL PHOBIA

DSM-IV-R criteria

• Marked and persistent fear of one or more situations in which the individual will be exposed to unfamiliar people or to scrutiny.• Exposure to the feared social situation nearly always produces considerable anxiety.• The individual recognises that the fear experienced is excessive.• The feared situations are either avoided or responded to with great anxiety.• The phobic reactions interfere significantly with the individual's working or social life, or there is marked distress.• Incidence: 70% of sufferers are female.

Research

The following sections outline the suggested aetiology (causes) of social phobia:

Fyer et al. (1993; cf. in Michael Eysenck’s PiP (2004) p.838) found 16% rate in close relatives of sufferers compared with 5% of relatives of non-sufferers.

Stemberger et al. (1995; cf. in Michael Eysenck’s PiP (2004) p.838) found that most social phobics were extremely introverted, a personality characteristic that depends in part on genetic factors. However, it is possible than the phobic condition has caused the introversion.

Social factors

Arrindell et al. (1989; cf. in Michael Eysenck’s PiP (2004) p.838) reported social phobics as regarding their parents as rejecting, lacking in emotional warmth, or over-protective. However, Hudson and Rapee (2000; cf. in Michael Eysenck’s PiP (2004) p.838) point out that children with an anxious temperament may induce this behaviour in their parents.

Bruch and Heimberg (1994; cf. in Michael Eysenck’s PiP (2004) p.838) suggest that parents of social phobics may pay too much heed to others' opinions, too little to family sociability, and tend to isolate their family from others.

4. SPECIFIC PHOBIA

This involves a strong and irrational fear of some specific object or situation. Common specific phobias are phobia of spiders, snakes, heights.

DSM-IV-R criteria

According to DSM-IV the main symptoms of specific phobia involve;

• A marked and persistent fear of a specific object or situation.• A recognition by the individual that his/her fear is excessive.• The phobic stimulus is avoided or responded to with great anxiety.• The phobic reactions are distressing and/or disruptive of working or social life.• The following sections outline the suggested aetiology (causes) of specific phobia.

Research

Fyer et al. (1990; cf. in Michael Eysenck’s PiP (2004) p.839) found a 32% rate in close relatives of sufferers.

Ost (1989; cf. in Michael Eysenck’s PiP (2004) p.839) found that 64% of close relatives of blood phobics had the same specific phobia.

As seen earlier, Freud believed that a phobia was a defence against the anxiety caused by repressed sexual instincts as exampled by his case of Little Hans’ fear of horses, which Freud translated to be a symbolically represented fear of castration by his father for sexual urges towards his mother.

Behavioural model

Phobias are the result of classical conditioning (CC): At some time the phobic object or situation has been present when a naturally fearful event has occurred and, by association, the individual has learnt to be afraid of the object. This fear is often generalised to similar objects or situations.

Evidence

This was demonstrated by Watson and Rayner (1920; cf. in Michael Eysenck’s PiP (2004) p.839) on ‘Little Albert’. However, it has difficult to replicate (Hallam & Rachman, 1976; cf. in Michael Eysenck’s PiP (2004) p.840).

Barlow and Durand (1995; cf. in Michael Eysenck’s PiP (2004) p.840) found that nearly everyone with a choking phobia had had a disagreeable choking experience in the past.

Keuthen (1980; cf. in Michael Eysenck’s PiP (2004) p.840) reported that 50% of phobics could not recall having had a related unpleasant occurrence. However, it's possible that this had been forgotten, especially if it occurred in early life. Nevertheless Menzies and Clarke (1993; cf. in Michael Eysenck’s PiP (2004) p.840) reported that 56% of water phobics maintained they had always been water phobic right from the first encounter.

The most significant evidence against this view comes from the hugely varying incidence of certain phobias—while spider and snake phobias are common, fear of many other things, including electrical products which can cause painful shocks, are not. Seligman (1971; cf. in Michael Eysenck’s PiP (2004) p.840) argues for preparedness—a combination of learning and biology. This states that due to evolution we are biologically wired to learn fear of things and situations that have the potential of being harmful to us.

It can be said that bio-physiological approaches tell us much about how anxiety occurs rather than why it occurs. So what certain conclusions may be drawn, at this point, on the complex phenomenon known simply as anxiety? We have touched upon the complex area of anxiety disorders and found, unsurprisingly, that there are several, more often than not overlapping, major anxiety disorders including: NEURASTHENIA, HYSTERIA, ANXIETY NEUROSIS, ‘STRESS’, PANIC DISORDER, POST-TRAUMATIC STRESS DISORDER, SOCIAL PHOBIAS, AND SPECIFIC PHOBIAS. What is clear - though much in this field is still opaque - is that most of these terminological dysfunctions can be treated most effectively when the conditions are right, such as for instance: early diagnosis is made possible, ‘good enough’ counselling and psychotherapy is given as required, prescriptive medications are effectively administered and managed, and the patient-client is monitored and managed within a structured clinical setting. Notwithstanding the complexity of the situation in locating anxiety; one where absolute clarity (of the Schopenhauerian kind) is indeed a naïve position to take, it appears that as human beings (whatever that may actually mean) we may be biologically predisposed to be sensitive (say, by an acquired ‘expectancy’) to certain stimuli - like the colours red and yellow, or the forms of spiders and snakes. The patterning of behaviour does not affect everyone to the same degree due to the complex matrix of biological, psychological and socio-relational factors in every case. It appears then that a healthy openness and respect toward the uniqueness of each case of anxiety (and their causes) are not misplaced; though patterns continue to emerge through more hypotheses and research testing drawn from pure psychology and pure natural science alike.

So What Is Psychotherapy?

Let us begin by stating that psychotherapy is not something that happens between any two people. Rather it is a socially accepted professional institution which has become embedded in the culture of modern industrialised societies. Therapy is an occupation for some, and a vocation for others. It is also safe to say that it is a professional discipline which is constantly evolving, and as such, requires of its varied practitioners an openness to the exploration and understanding of contemporary culture and individual difference, and, perhaps, the problematic relation of the particular to the universal found within the historiography of what has been broadly called the philosophies of mind. There has also been considerable debate as to the difference between the descriptions for counselling and psychotherapy. On the one hand, there are those that say they are basically the same thing – in that they both provide the same human service. On the other, there are those that say that psychotherapy is an up-market version provided by very highly trained specialist professionals, some with a background in psychiatry. What can safely be said in relation to the debate is that most counselling is conducted by non-professional volunteer workers, whereas, psychotherapy tends to be an exclusively professional occupation. Another term which is increasingly being used is that of counselling psychologist. Here, this refers to a counsellor who also holds a psychological based education or degree in psychology. But that it was so simple, as there are also counsellors who specialise with certain client groups: mental health counsellors, marriage counsellors, substance abuse counsellors and student counsellors to name but four. To this mix we might then make the observation that a counselling training may take anything from two weeks to four years; and that standard psychotherapy trainings may take anything from two years to four years. From this clearly complex situation we may at least draw one definite conclusion; that is, there is no quick answer to the ongoing debate on that which might constitute the main differences between counselling and psychotherapy, instead one ought to perhaps look closer at the practice and qualifications of the individual practitioner. ‘The explosion of ideas between the 1950s and 1970s’, writes Karasu (HANDBOOK OF PSYCHOTHERAPY, 1986), ‘have meant that there may be as many as four hundred distinct models of counselling and psychotherapy.’ Today, thirty years on, who knows how many new therapies there could be? Nonetheless, the main theoretical perspectives can be said to fall under one of these main headings: Systemic, Cognitive-Analytic, Cognitive-Behavioural, and Solution-Focused. That said, there are others who would have us believe that this distinction could be narrowed further by using another distinction, that of therapy duration, as seen by: Brief therapy, Time-limited therapy, and Long-term therapy. That having been noted, one might be suggested to do well to remember that all psychotherapeutic counselling really ought to be founded on client-centred principles. For otherwise, who are we left to suppose the therapeutic work might otherwise be centred upon?